Provider Demographics
NPI:1215412317
Name:PETERSON, KEVIN BRADLEY (AUD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:BRADLEY
Last Name:PETERSON
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21911 76TH AVE W STE 211
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026-7918
Mailing Address - Country:US
Mailing Address - Phone:425-775-6651
Mailing Address - Fax:425-670-6718
Practice Address - Street 1:21911 76TH AVE W STE 211
Practice Address - Street 2:
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-7918
Practice Address - Country:US
Practice Address - Phone:425-775-6651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-25
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALD60889235237600000X, 231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2108044Medicaid