Polly W. Peterson, PH.D.

Primary specialty

PsychologistTaxonomy code 103T00000X

Legal business name

POLLY W. PETERSON, PH.D.

Practice address

1543 Kingsley Ave Ste 14
Orange Park, FL 32073-4570

Phone

(904) 742-8235

Fax

(904) 217-7222

NPI assigned

Feb 11, 2022

Last updated

Feb 11, 2022By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Dr. Polly Wietzke Peterson, PHDNPI 1902929698

Title

Psychologist/Owner

Phone

(904) 742-8164

Specialties & licenses 1

Addresses

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Polly Wietzke Peterson, PH.D.

  • School Psychologist
  • Orange Park, FL
  • NPI 1902929698
  NPD Authorized official

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

{
    "created_epoch": "1644537600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1644537600000",
    "number": "1427702091",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2465 US HIGHWAY 1 S UNIT 154",
            "city": "SAINT AUGUSTINE",
            "state": "FL",
            "postal_code": "320866076",
            "telephone_number": "904-742-8164",
            "fax_number": "904-217-7222"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1543 KINGSLEY AVE STE 14",
            "city": "ORANGE PARK",
            "state": "FL",
            "postal_code": "320734570",
            "telephone_number": "904-742-8235",
            "fax_number": "904-217-7222"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "POLLY W. PETERSON, PH.D.",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-02-11",
        "last_updated": "2022-02-11",
        "certification_date": "2022-02-11",
        "status": "A",
        "authorized_official_last_name": "PETERSON",
        "authorized_official_first_name": "POLLY",
        "authorized_official_middle_name": "WIETZKE",
        "authorized_official_title_or_position": "PSYCHOLOGIST/OWNER",
        "authorized_official_telephone_number": "904-742-8164",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "PHD"
    },
    "taxonomies": [
        {
            "code": "103T00000X",
            "taxonomy_group": "",
            "desc": "Psychologist",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Jennifer Peterson Poe
• Pointe Med Pharmacy, Inc.
• Pointe Medical Services Inc
• Shradha Pokharel, MD
• Alysha Marie Polk
• Teresa Marie Ponder, PHARM D
• Robert Charles Ponte
• Gabriella Poole
• Regina Poole, LMHC, LPC, LCMHC
• Scott Poortinga, DDS

• Psychologist in Orange Park, FL
• Providers in Orange Park, FL by specialty
• Psychologist in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 11, 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.