Provider Demographics
NPI:1598012825
Name:PETERS, KRISTEN MARIE (LICSW)
Entity Type:Individual
Prefix:MS
First Name:KRISTEN
Middle Name:MARIE
Last Name:PETERS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1395 ATWOOD AVE
Mailing Address - Street 2:SUITE 203A
Mailing Address - City:JOHNSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02919-4929
Mailing Address - Country:US
Mailing Address - Phone:401-262-0210
Mailing Address - Fax:
Practice Address - Street 1:1395 ATWOOD AVE
Practice Address - Street 2:SUITE 203A
Practice Address - City:JOHNSTON
Practice Address - State:RI
Practice Address - Zip Code:02919-4929
Practice Address - Country:US
Practice Address - Phone:401-262-0210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-06
Last Update Date:2015-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW02228101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI202995889Medicaid