1366067258 NPI number — DR. KIRSTEN E. PETERSEN PSYCHOLOGICAL SERVICES, PLLC

Table of content: (NPI 1366067258)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366067258 NPI number — DR. KIRSTEN E. PETERSEN PSYCHOLOGICAL SERVICES, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR. KIRSTEN E. PETERSEN PSYCHOLOGICAL SERVICES, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366067258
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/17/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2389 BABYLON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WANTAGH
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11793-4501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
917-991-1042
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2389 BABYLON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WANTAGH
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11793-4501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
917-991-1042
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/16/2020

Additional Information

Authorized Official

Authorized Official Last Name:
PETERSEN
Authorized Official First Name:
KIRSTEN
Authorized Official Middle Name:
ERIN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
917-991-1042

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 901260 . This is a "BEACON HEALTH OPTIONS" identifier . This identifiers is of the category "OTHER".
  • Identifier: V53P52 . This is a "EMPIRE BLUECROSS BLUESHIELD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com