Provider records sourced from NPPES (CMS National Plan & Provider Enumeration System). Data current as of August 10, 2026.

Dr. Polly Wietzke Peterson, PHD

Individual provider School Psychologist · NPI 1902929698

Dr. Polly Wietzke Peterson, PHD is a Clinical Psychologist in Orange Park, Florida. Qualified in 1973, 53 years ago. Practices as a sole proprietor, accepts Medicare assignment and offers telehealth. Licensed in Florida.

Years since qualifying
53
Licensed in
FL
In the registry since
2007
What do these letters mean?
PHD — Doctor of Philosophy
A research doctorate. In healthcare it usually sits alongside a clinical licence.

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Practice location Address checks out

1543 Kingsley Ave Ste 14
Orange Park, FL 32073-4570
Phone: (904) 742-8164
Fax: (904) 217-7222
Show map & directions

Pin is approximate — placed at the ZIP-code centre, not the exact door.

Specialties & licences

School Psychologist (primary) Taxonomy 103TS0200X · Licence SS495 (FL)

Record details

NPI number1902929698
Entity typeIndividual (Type 1)
GenderFemale
Credentials PHD
Sole proprietorYes
NPI enumeratedApril 9, 2007
Last updated in NPPESMarch 12, 2021
Certification dateDecember 24, 2020

Medicare enrollment

From the CMS Doctors & Clinicians file — this clinician is enrolled in Medicare.

Medicare specialtyCLINICAL PSYCHOLOGIST
Medical schoolOTHER
Graduated 1973 (53 years in practice)
Accepts Medicare assignment Yes — accepts the Medicare-approved amount
TelehealthOffers telehealth services

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