Active NPI
Keith R Peterson, PHD
- Clinical Psychologist
- Irvine, CA
National Provider Identifier
1023144573
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Psychologist
- License
- PSY 15859
- Practice address
- 6 Venture
Suite 350
Irvine, CA 92618-3340 - Phone
- (949) 683-8789
- Fax
- (949) 581-4484
- NPI assigned
- Feb 26, 2007
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Psychologist | 103TC0700X | PSY 15859 | CA | Primary |
Addresses
Primary practice location
6 Venture
Suite 350
Irvine, CA 92618-3340
Mailing address
26741 Portola Pkwy
Suite 1E 432
Foothill Ranch, CA 92610-1743
Phone (949) 683-8789
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in CA
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: No
- Power mobility devices: No
- Hospice: No
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20060317000564 | CA | Practitioner - Clinical Psychologist | 8729095633 | Practice locations: Irvine, CA |
Care Compare profile
Medicare Care Compare- Specialty
- Clinical Psychologist
- Education
- Other, 1995
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
Practice addresses (Care Compare)
6 Venture
Suite 350
Irvine, CA 92618-7350
Phone (949) 683-8789
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Philosophy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| PSY 15859 | CA | MD | Clinical Psychologist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1172448000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1023144573",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "26741 PORTOLA PKWY",
"address_2": "SUITE 1E 432",
"city": "FOOTHILL RANCH",
"state": "CA",
"postal_code": "926101743",
"telephone_number": "949-683-8789",
"fax_number": "949-581-4484"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "6 VENTURE",
"address_2": "SUITE 350",
"city": "IRVINE",
"state": "CA",
"postal_code": "926183340",
"telephone_number": "949-683-8789",
"fax_number": "949-581-4484"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PETERSON",
"first_name": "KEITH",
"middle_name": "R",
"name_prefix": "Dr.",
"credential": "PHD",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2007-02-26",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "CA",
"license": "PSY 15859",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Irvine, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.