Provider Demographics
NPI:1932399938
Name:PETERSON, DOUGLAS ALLEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:ALLEN
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2632 WORDEN ST.
Mailing Address - Street 2:189
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-5841
Mailing Address - Country:US
Mailing Address - Phone:619-223-8511
Mailing Address - Fax:
Practice Address - Street 1:16935 W BERNARDO DR
Practice Address - Street 2:238
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92127-1634
Practice Address - Country:US
Practice Address - Phone:619-223-8511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-26
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 20082103TC0700X, 103TH0004X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist