Provider Demographics
NPI:1336641562
Name:PETERSON, KRISTIN MICHELLE (MSW)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:MICHELLE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2849 GOLFSIDE RD APT 43
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-1945
Mailing Address - Country:US
Mailing Address - Phone:734-330-8050
Mailing Address - Fax:
Practice Address - Street 1:110 N 4TH AVE
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-5503
Practice Address - Country:US
Practice Address - Phone:734-330-8050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-03
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011021961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical