Provider Demographics
NPI:1104070119
Name:PETERSEN, TIMOTHY ALLEN (PSYD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:ALLEN
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16055 VENTURA BLVD
Mailing Address - Street 2:SUITE 920
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2601
Mailing Address - Country:US
Mailing Address - Phone:818-377-6330
Mailing Address - Fax:
Practice Address - Street 1:16055 VENTURA BLVD
Practice Address - Street 2:SUITE 920
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2601
Practice Address - Country:US
Practice Address - Phone:818-377-6330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-05
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 19159103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist