Active NPI
Melissa Edwards Petersen, PHD
- Clinical Neuropsychologist
- Fort Worth, TX
National Provider Identifier
1144860917
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Neuropsychologist
- License
- 36939
- Practice address
- 855 Montgomery St
Fort Worth, TX 76107-2553 - Phone
- (817) 735-2200
- NPI assigned
- Jan 9, 2020
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Neuropsychologist | 103G00000X | 36939 | TX | Primary |
| Clinical Psychologist | 103TC0700X | 36939 | TX |
Addresses
Primary practice location
855 Montgomery St
Fort Worth, TX 76107-2553
Mailing address
855 Montgomery St
Fort Worth, TX 76107-2553
Phone (817) 735-2200
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Philosophy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 36939 | TX | MD | Dentist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1578528000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1602720000000",
"number": "1144860917",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "855 MONTGOMERY ST",
"city": "FORT WORTH",
"state": "TX",
"postal_code": "761072553",
"telephone_number": "817-735-2200"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "855 MONTGOMERY ST",
"city": "FORT WORTH",
"state": "TX",
"postal_code": "761072553",
"telephone_number": "817-735-2200"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PETERSEN",
"first_name": "MELISSA",
"middle_name": "EDWARDS",
"credential": "PHD",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2020-01-09",
"last_updated": "2020-10-15",
"certification_date": "2020-10-15",
"status": "A"
},
"taxonomies": [
{
"code": "103G00000X",
"taxonomy_group": "",
"desc": "Clinical Neuropsychologist",
"state": "TX",
"license": "36939",
"primary": true
},
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "TX",
"license": "36939",
"primary": false
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Fort Worth, TX
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 15, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.