Provider Demographics
NPI:1457655680
Name:PETERSEN, KEVIN W
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:W
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 S CLARKSON ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80210-2237
Mailing Address - Country:US
Mailing Address - Phone:970-310-7083
Mailing Address - Fax:
Practice Address - Street 1:1420 S CLARKSON ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80210-2237
Practice Address - Country:US
Practice Address - Phone:970-310-7083
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-03
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist