Active NPI
Leland W Petersen, CP
- Clinical Psychologist
- Glen Head, NY
National Provider Identifier
1790902229
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Psychologist
- License
- 05430
- Practice address
- 11 Beechwood Dr
Glen Head, NY 11545-1101 - Phone
- (516) 671-7509
- NPI assigned
- Apr 19, 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 | 05430 | NY | Primary |
Addresses
Primary practice location
11 Beechwood Dr
Glen Head, NY 11545-1101
Mailing address
11 Beechwood Dr
Glen Head, NY 11545-1101
Phone (516) 671-7509
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
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 05430 | NY | MD | Clinical Psychologist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1176940800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1193788800000",
"number": "1790902229",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "11 BEECHWOOD DR",
"city": "GLEN HEAD",
"state": "NY",
"postal_code": "115451101",
"telephone_number": "516-671-7509"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "11 BEECHWOOD DR",
"city": "GLEN HEAD",
"state": "NY",
"postal_code": "115451101",
"telephone_number": "516-671-7509"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PETERSEN",
"first_name": "LELAND",
"middle_name": "W",
"credential": "CP",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2007-04-19",
"last_updated": "2007-10-31",
"status": "A"
},
"taxonomies": [
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "NY",
"license": "05430",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Glen Head, NY
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 31, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.