Provider Demographics
NPI:1902929698
Name:PETERSON, POLLY WIETZKE (PHD)
Entity Type:Individual
Prefix:DR
First Name:POLLY
Middle Name:WIETZKE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2465 US HIGHWAY 1 S UNIT 154
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-6076
Mailing Address - Country:US
Mailing Address - Phone:904-742-8235
Mailing Address - Fax:904-217-7222
Practice Address - Street 1:1543 KINGSLEY AVE STE 14
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4570
Practice Address - Country:US
Practice Address - Phone:904-742-8164
Practice Address - Fax:904-217-7222
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSS495103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ0537OtherBLUE CROSS BLUE SHIELD FL
FL346340500OtherUS DEPARTMENT OF LABOR
FLZ8341OtherBLUE CROSS BLUE SHIELD FL