Provider Demographics
NPI:1104996446
Name:PETERSON, BETTY (PHD)
Entity type:Individual
Prefix:
First Name:BETTY
Middle Name:
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 1:4310 MEDICAL PKWY
Mailing Address - Street 2:STE 101
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78756-3335
Mailing Address - Country:US
Mailing Address - Phone:512-345-9900
Mailing Address - Fax:512-329-7675
Practice Address - Street 1:4310 MEDICAL PKWY
Practice Address - Street 2:STE 101
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78756-3335
Practice Address - Country:US
Practice Address - Phone:512-345-9900
Practice Address - Fax:512-329-7675
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25248103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00117PMedicare ID - Type UnspecifiedPROVIDER NUMBER