Provider Demographics
NPI:1467955724
Name:PETERSON, KIMBERLY ROSE (LMSW)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ROSE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 FORT HILL AVE
Mailing Address - Street 2:
Mailing Address - City:CANANDAIGUA
Mailing Address - State:NY
Mailing Address - Zip Code:14424-1159
Mailing Address - Country:US
Mailing Address - Phone:585-615-0183
Mailing Address - Fax:
Practice Address - Street 1:400 FORT HILL AVE
Practice Address - Street 2:
Practice Address - City:CANANDAIGUA
Practice Address - State:NY
Practice Address - Zip Code:14424-1159
Practice Address - Country:US
Practice Address - Phone:585-615-0183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-13
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY100075101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty