Provider Demographics
NPI:1104632991
Name:PETTERSEN, KATRINA LAREA (LEP 4489)
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:LAREA
Last Name:PETTERSEN
Suffix:
Gender:F
Credentials:LEP 4489
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2893 UNION AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95124-1435
Mailing Address - Country:US
Mailing Address - Phone:760-902-8990
Mailing Address - Fax:
Practice Address - Street 1:1261 LINCOLN AVE STE 104
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95125-3030
Practice Address - Country:US
Practice Address - Phone:408-439-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-05
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4489103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool