Provider Demographics
NPI:1609510858
Name:PETERSEN, KATHLEEN MICHELLE (PHD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:MICHELLE
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 WATER ST STE 208
Mailing Address - Street 2:
Mailing Address - City:EXCELSIOR
Mailing Address - State:MN
Mailing Address - Zip Code:55331-1887
Mailing Address - Country:US
Mailing Address - Phone:612-615-3575
Mailing Address - Fax:
Practice Address - Street 1:202 WATER ST STE 208
Practice Address - Street 2:
Practice Address - City:EXCELSIOR
Practice Address - State:MN
Practice Address - Zip Code:55331-1887
Practice Address - Country:US
Practice Address - Phone:612-615-3575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-25
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5567103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool