Provider Demographics
NPI:1124109400
Name:PETERSEN, WILLIAM C (PHD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:C
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7106 DALE AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HEIGHTS
Mailing Address - State:MO
Mailing Address - Zip Code:63117-1927
Mailing Address - Country:US
Mailing Address - Phone:314-647-6303
Mailing Address - Fax:
Practice Address - Street 1:5351 DELMAR BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63112-3146
Practice Address - Country:US
Practice Address - Phone:314-877-0685
Practice Address - Fax:314-877-0553
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01531103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000070864Medicare PIN