Provider Demographics
NPI:1578759270
Name:PETERSEN, KEVIN LEE (LMHC)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:LEE
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 16TH ST SE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55904-7973
Mailing Address - Country:US
Mailing Address - Phone:507-315-4184
Mailing Address - Fax:507-516-0031
Practice Address - Street 1:401 16TH ST SE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55904-7973
Practice Address - Country:US
Practice Address - Phone:507-315-4184
Practice Address - Fax:507-516-0031
Is Sole Proprietor?:No
Enumeration Date:2007-09-18
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP6513103TC0700X
IA00399101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health