Provider Demographics
NPI:1497230361
Name:KIRKLAND, PETER SR (CP00005495)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:KIRKLAND
Suffix:SR
Gender:M
Credentials:CP00005495
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4625 124TH AVENUE CT E
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98372-9278
Mailing Address - Country:US
Mailing Address - Phone:252-222-7330
Mailing Address - Fax:
Practice Address - Street 1:17002 PACIFIC AVE S
Practice Address - Street 2:
Practice Address - City:SPANAWAY
Practice Address - State:WA
Practice Address - Zip Code:98387-8253
Practice Address - Country:US
Practice Address - Phone:253-538-2323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-26
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP0005495101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)