Mark Peterson, PSY.D.

Primary specialty

Clinical PsychologistTaxonomy code 103TC0700X

License

PSB94026068 Issued in CA

Practice address

8911 Lakewood Dr # 26a
Windsor, CA 95492-7856

Phone

(916) 798-7072

NPI assigned

Jan 28, 2022

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1643328000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1643328000000",
    "number": "1417600511",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "9033 ACORN RIDGE CIR",
            "city": "ELK GROVE",
            "state": "CA",
            "postal_code": "957585413",
            "telephone_number": "916-798-7072"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "8911 LAKEWOOD DR # 26A",
            "city": "WINDSOR",
            "state": "CA",
            "postal_code": "954927856",
            "telephone_number": "916-798-7072"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "9033 Acorn Ridge Cir",
            "address_purpose": "LOCATION",
            "city": "Elk Grove",
            "state": "CA",
            "postal_code": "957585413",
            "country_code": "US",
            "telephone_number": "916-798-7072",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "PETERSON",
        "first_name": "MARK",
        "name_prefix": "Dr.",
        "credential": "PSY.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2022-01-28",
        "last_updated": "2022-01-28",
        "certification_date": "2022-01-28",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "CA",
            "license": "PSB94026068",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "18611570000",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Clinical Psychologist in Windsor, CA
• Providers in Windsor, CA by specialty
• Clinical Psychologist in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 28, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.