Provider Demographics
NPI:1154075836
Name:PETERSON, KAILEY (MSW, CAPSW, SAC-IT)
Entity Type:Individual
Prefix:
First Name:KAILEY
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MSW, CAPSW, SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 EMIL ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53713-2311
Mailing Address - Country:US
Mailing Address - Phone:608-421-3406
Mailing Address - Fax:608-283-6374
Practice Address - Street 1:1409 EMIL ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53713-2311
Practice Address - Country:US
Practice Address - Phone:608-421-3406
Practice Address - Fax:608-283-6374
Is Sole Proprietor?:No
Enumeration Date:2022-02-10
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19452-130101YA0400X
WI132464-121104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)