Provider Demographics
NPI:1043528334
Name:PETERSON, KACEY M (MS, LMHC)
Entity Type:Individual
Prefix:
First Name:KACEY
Middle Name:M
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MS, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 E GRANT ST
Mailing Address - Street 2:
Mailing Address - City:CASEY
Mailing Address - State:IA
Mailing Address - Zip Code:50048-1011
Mailing Address - Country:US
Mailing Address - Phone:641-247-8114
Mailing Address - Fax:
Practice Address - Street 1:320 NE 3RD ST
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:IA
Practice Address - Zip Code:50250-2157
Practice Address - Country:US
Practice Address - Phone:641-247-8114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-20
Last Update Date:2015-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001334101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health