Provider Demographics
NPI:1508048554
Name:KEVIN H. PETERSON
Entity Type:Organization
Organization Name:KEVIN H. PETERSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:HOWARD
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:301-759-3360
Mailing Address - Street 1:12517 ELLIS RD NE
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21502-6876
Mailing Address - Country:US
Mailing Address - Phone:301-759-3360
Mailing Address - Fax:
Practice Address - Street 1:31 BALTIMORE ST
Practice Address - Street 2:SUITE 103
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-3072
Practice Address - Country:US
Practice Address - Phone:301-759-3360
Practice Address - Fax:301-759-3360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-01
Last Update Date:2009-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD02746103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD207NMedicare PIN