Polly Wietzke Peterson, PH.D.

Primary specialty

School PsychologistTaxonomy code 103TS0200X

License

SS495 Issued in FL

Practice address

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

Phone

(904) 742-8164

Fax

(904) 217-7222

NPI assigned

Apr 9, 2007

Sex

Female

Sole proprietor

Yes

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

Specialties & licenses 1

Addresses

Other identifiers 3

Medicare fee-for-service enrollment

Enrolled in FL

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Clinical Psychologist

Education

Other, 1973

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Telehealth

Offers telehealth services

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Philosophy

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Polly W. Peterson, PH.D.

  • Psychologist
  • Orange Park, FL
  • NPI 1427702091
  NPD Authorized official

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

{
    "created_epoch": "1176076800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1615507200000",
    "number": "1902929698",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2465 US HIGHWAY 1 S UNIT 154",
            "city": "ST AUGUSTINE",
            "state": "FL",
            "postal_code": "320866076",
            "telephone_number": "904-742-8235",
            "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": "904-742-8164",
            "fax_number": "904-217-7222"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PETERSON",
        "first_name": "POLLY",
        "middle_name": "WIETZKE",
        "name_prefix": "Dr.",
        "credential": "PH.D.",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2007-04-09",
        "last_updated": "2021-03-12",
        "certification_date": "2020-12-24",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103TS0200X",
            "taxonomy_group": "",
            "desc": "Psychologist, School",
            "state": "FL",
            "license": "SS495",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD FL",
            "identifier": "Z0537",
            "state": "FL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "US DEPARTMENT OF LABOR",
            "identifier": "346340500",
            "state": "FL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD FL",
            "identifier": "Z8341",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Peter J. Pitocchi MD PA
• Alyssa J Peterson, ED.S.
• Edriel Peterson
• Cynthia Jean Petito, OTR/L
• Holland Petree
• Creighton John Pfau, DO
• Kaitlin Elizabeth Pfeiffer
• Thi Anh Pham, PHARMACIST

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

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 12, 2021; 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.

Verify at the official NPI Registry.