Provider Demographics
NPI:1548442874
Name:PETERSON, CAROLYN ANN (PHD)
Entity type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:ANN
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 1:3215 FORTUNE CT
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:CA
Mailing Address - Zip Code:95602-9245
Mailing Address - Country:US
Mailing Address - Phone:530-613-9217
Mailing Address - Fax:530-889-2420
Practice Address - Street 1:3215 FORTUNE CT
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95602-9245
Practice Address - Country:US
Practice Address - Phone:530-613-9217
Practice Address - Fax:530-889-2420
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-28
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY16440103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist