Provider Demographics
NPI:1003856634
Name:PETERSON, KATHRYN LOUISE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:LOUISE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 E BIRCH AVE
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-4609
Mailing Address - Country:US
Mailing Address - Phone:928-213-0068
Mailing Address - Fax:928-774-4367
Practice Address - Street 1:115 E BIRCH AVE
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-4609
Practice Address - Country:US
Practice Address - Phone:928-213-0068
Practice Address - Fax:928-774-4367
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-40481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical