Provider Demographics
NPI:1689964553
Name:PETERSON, KRISTINE (LCSW)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 RIVERSIDE DR
Mailing Address - Street 2:3A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024-3708
Mailing Address - Country:US
Mailing Address - Phone:646-287-1207
Mailing Address - Fax:
Practice Address - Street 1:118 RIVERSIDE DR
Practice Address - Street 2:3A
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-3708
Practice Address - Country:US
Practice Address - Phone:646-287-1207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-13
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY73 789501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical