Provider Demographics
NPI:1316324700
Name:PETERSON, POLLY (PHD)
Entity type:Individual
Prefix:DR
First Name:POLLY
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:PO BOX 448
Mailing Address - Street 2:
Mailing Address - City:ANACONDA
Mailing Address - State:MT
Mailing Address - Zip Code:59711-0448
Mailing Address - Country:US
Mailing Address - Phone:406-560-3097
Mailing Address - Fax:
Practice Address - Street 1:125 W GRANITE ST STE 212
Practice Address - Street 2:
Practice Address - City:BUTTE
Practice Address - State:MT
Practice Address - Zip Code:59701-9215
Practice Address - Country:US
Practice Address - Phone:406-560-3097
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-05
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPSY-PSY-LIC-337103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical