Provider Demographics
NPI:1720371933
Name:PETERSON, KERRY (MA, CCC/SLP, BCBA)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MA, CCC/SLP, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4290 BOULDER POND DR
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-8624
Mailing Address - Country:US
Mailing Address - Phone:248-737-3430
Mailing Address - Fax:248-737-3433
Practice Address - Street 1:6625 DALY RD
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3410
Practice Address - Country:US
Practice Address - Phone:248-737-3430
Practice Address - Fax:248-737-3433
Is Sole Proprietor?:No
Enumeration Date:2011-05-20
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist