Provider Demographics
NPI:1417423419
Name:PETERS, KEITHA EVA
Entity Type:Individual
Prefix:MS
First Name:KEITHA
Middle Name:EVA
Last Name:PETERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 W 15TH ST
Mailing Address - Street 2:
Mailing Address - City:LIBERAL
Mailing Address - State:KS
Mailing Address - Zip Code:67901-2455
Mailing Address - Country:US
Mailing Address - Phone:620-624-8171
Mailing Address - Fax:620-624-0114
Practice Address - Street 1:333 W 15TH ST
Practice Address - Street 2:
Practice Address - City:LIBERAL
Practice Address - State:KS
Practice Address - Zip Code:67901-2455
Practice Address - Country:US
Practice Address - Phone:620-624-8171
Practice Address - Fax:620-624-0114
Is Sole Proprietor?:No
Enumeration Date:2018-10-17
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2874103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist