Provider Demographics
NPI:1033226733
Name:PETERSON, KEVIN CHRISTOPHER (PHD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:CHRISTOPHER
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4026 NE 55TH ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98105-2262
Mailing Address - Country:US
Mailing Address - Phone:206-526-1284
Mailing Address - Fax:206-526-1284
Practice Address - Street 1:4026 NE 55TH ST
Practice Address - Street 2:SUITE D
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-2262
Practice Address - Country:US
Practice Address - Phone:206-526-1284
Practice Address - Fax:206-526-1284
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA0000536103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical