Provider Demographics
NPI:1699902759
Name:PETERSON, MICHAEL ALEX (PHD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ALEX
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:ALEX
Other - Middle Name:
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:1425 LEIMERT BLVD
Mailing Address - Street 2:SUITE 403
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94602-1865
Mailing Address - Country:US
Mailing Address - Phone:510-531-0500
Mailing Address - Fax:510-336-0902
Practice Address - Street 1:1425 LEIMERT BLVD
Practice Address - Street 2:SUITE 403
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94602-1865
Practice Address - Country:US
Practice Address - Phone:510-531-0500
Practice Address - Fax:510-336-0902
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-16
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18593103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist