Provider Demographics
NPI:1366067258
Name:DR. KIRSTEN E. PETERSEN PSYCHOLOGICAL SERVICES, PLLC
Entity type:Organization
Organization Name:DR. KIRSTEN E. PETERSEN PSYCHOLOGICAL SERVICES, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIRSTEN
Authorized Official - Middle Name:ERIN
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-991-1042
Mailing Address - Street 1:2389 BABYLON ST
Mailing Address - Street 2:
Mailing Address - City:WANTAGH
Mailing Address - State:NY
Mailing Address - Zip Code:11793-4501
Mailing Address - Country:US
Mailing Address - Phone:917-991-1042
Mailing Address - Fax:
Practice Address - Street 1:2389 BABYLON ST
Practice Address - Street 2:
Practice Address - City:WANTAGH
Practice Address - State:NY
Practice Address - Zip Code:11793-4501
Practice Address - Country:US
Practice Address - Phone:917-991-1042
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-16
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
901260OtherBEACON HEALTH OPTIONS
NYV53P52OtherEMPIRE BLUECROSS BLUESHIELD