Provider Demographics
NPI:1508307836
Name:PETERSON, KIMBERLY PAVICH
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:PAVICH
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIMBER
Other - Middle Name:PAVICH
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:13861 OTIS PL
Mailing Address - Street 2:
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-4833
Mailing Address - Country:US
Mailing Address - Phone:760-815-8994
Mailing Address - Fax:
Practice Address - Street 1:6160 MISSION GORGE RD STE 108
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-3425
Practice Address - Country:US
Practice Address - Phone:760-815-8994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-20
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor