Individual
DR. POLLY WIETZKE PETERSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PH.D.
Contact information
Practice address
1543 KINGSLEY AVE STE 14, ORANGE PARK, FL 32073-4570
(904) 742-8164
(904) 217-7222
Mailing address
2465 US HIGHWAY 1 S UNIT 154, ST AUGUSTINE, FL 32086-6076
(904) 742-8235
(904) 217-7222
Taxonomy
Speciality
Code
Description
License number
State
103TS0200X
School Psychologist
Primary
SS495
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
346340500
US DEPARTMENT OF LABOR
FL
01
—
Z0537
BLUE CROSS BLUE SHIELD FL
FL
01
—
Z8341
BLUE CROSS BLUE SHIELD FL
FL
Enumeration date
04/09/2007
Last updated
03/12/2021
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