Provider Demographics
NPI:1225396583
Name:PETERSON, KIMBERLY (MA, MFTI)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MA, MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1160 N DUTTON AVE
Mailing Address - Street 2:SUIT 105
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-4600
Mailing Address - Country:US
Mailing Address - Phone:707-326-9277
Mailing Address - Fax:
Practice Address - Street 1:1160 N DUTTON AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-4600
Practice Address - Country:US
Practice Address - Phone:707-545-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-24
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA65068106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health