DR. POLLY WIETZKE PETERSON (PH.D.) – School Psychologist, NPI 1902929698
School Psychologist
Main info
Doctor Profile
Profile Insights
NPPES metrics only — not quality of care.
1,602 CLINICAL PSYCHOLOGIST in FL
Provider Addresses for DR. POLLY WIETZKE PETERSON (PH.D.)
1543 KINGSLEY AVE STE 14
ORANGE PARK, FL 320734570
Phone: (904) 375-9679
Fax: (904) 269-0870
Type: Mailing
1555 KINGSLEY AVE
ORANGE PARK, FL 320739201
Phone: (904) 278-4999
Fax: (904) 278-8891
Type: Location
2465 US HIGHWAY 1 S UNIT 154
ST AUGUSTINE, FL 320866076
Phone: (904) 742-8235
Fax: (904) 217-7222
Type: Mailing
NPPES updates history
No NPPES updates recorded for this provider.
Prescription Activity
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Open Payments (CMS)
No Open Payments data available for this provider.
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Medicare Enrollment & Revalidation
Source: CMS public data · Not endorsed by CMS ·
Educational use only—not medical, billing, or legal advice.
PECOS enrollment status
Participating (accepts Medicare assignment)
Enrollment effective: 2020-06-15
PECOS data refreshed: 2026-05-27
Medicare revalidation (CMS due date list)
Due date not assigned yet
CMS is tracking this Medicare enrollment for revalidation, but has not published a due date.
Enrollment records
1
Earliest due date
Not assigned (TBD)
CMS data updated
2026-06-01
Revalidation progress
- Medicare enrolled
- On CMS revalidation list
- Due date assigned
- Revalidate in PECOS
CMS enrollment records
| Enrollment ID | Type | Specialty | State | Due date |
|---|---|---|---|---|
| I20200615002521 | I | Clinical Psychologist | FL | TBD |
What to do next
- No action required while the due date shows TBD.
- Check the CMS Revalidation Lookup Tool periodically — CMS updates the list about every 60 days.
- Do not submit a revalidation application in PECOS until CMS publishes a concrete due date.
Prepare CMS-855 application → · Look up this NPI in PECOS → · Verify on CMS PECOS
Medicare Utilization (FFS)
Source: CMS public data · Not endorsed by CMS · Beneficiary counts under 11 are suppressed in source data ·
Educational use only—not medical, billing, or legal advice.
Top Medicare procedures (2023) · refreshed 2026-05-27
| HCPCS | Description | Services | Beneficiaries | Medicare allowed |
|---|---|---|---|---|
| 90785 | Psychiatric services complicated by communication factor | 130 | 16 | $0 |
| 90837 | Psychotherapy, 1 hour | 87 | 15 | $0 |
Insurance plans in this area (ZIP 32073)
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