Provider Demographics
NPI:1427419993
Name:PETERSON, KRISTINA (PHD, NCC, LPC)
Entity Type:Individual
Prefix:DR
First Name:KRISTINA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PHD, NCC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4455 S LEAMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60638-1910
Mailing Address - Country:US
Mailing Address - Phone:312-371-6807
Mailing Address - Fax:
Practice Address - Street 1:115 N MARION ST
Practice Address - Street 2:SUITE 1
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1503
Practice Address - Country:US
Practice Address - Phone:708-834-0909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-11
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.011641101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional