Provider Demographics
NPI:1174867022
Name:PETERSEN, KASEY GRAHAM (BCABA)
Entity Type:Individual
Prefix:
First Name:KASEY
Middle Name:GRAHAM
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 MATHER GREEN AVE APT C
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-5676
Mailing Address - Country:US
Mailing Address - Phone:803-524-9715
Mailing Address - Fax:
Practice Address - Street 1:89 OLD TROLLEY RD # B
Practice Address - Street 2:202
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29485-4951
Practice Address - Country:US
Practice Address - Phone:843-875-0017
Practice Address - Fax:843-486-8394
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst