Provider Demographics
NPI:1215169818
Name:PETERSEN, BRIAN A (PSYD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:A
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 1:156 WILLIAM ST
Mailing Address - Street 2:12TH FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10038-2609
Mailing Address - Country:US
Mailing Address - Phone:917-621-5822
Mailing Address - Fax:212-346-1530
Practice Address - Street 1:412 6TH AVE
Practice Address - Street 2:#610
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-8409
Practice Address - Country:US
Practice Address - Phone:917-621-5822
Practice Address - Fax:212-346-1530
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-14
Last Update Date:2009-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY# 016797-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical