Provider Demographics
NPI:1295929305
Name:PETERSON, SYDNEY
Entity type:Individual
Prefix:
First Name:SYDNEY
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6331 N 39TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85019-1553
Mailing Address - Country:US
Mailing Address - Phone:602-841-7445
Mailing Address - Fax:
Practice Address - Street 1:6331 N 39TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85019-1553
Practice Address - Country:US
Practice Address - Phone:602-841-7445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-31
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool