Provider Demographics
NPI:1598092603
Name:PETERSON, KIMBERLY (LPC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7418 STONEBRIDGE CREEK LN
Mailing Address - Street 2:
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77396-4142
Mailing Address - Country:US
Mailing Address - Phone:832-647-3835
Mailing Address - Fax:
Practice Address - Street 1:12371 S KIRKWOOD RD
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:TX
Practice Address - Zip Code:77477-2836
Practice Address - Country:US
Practice Address - Phone:713-995-9292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-10
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX63953101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional