Provider Demographics
NPI:1760116271
Name:PETERSON, KRISTEN B
Entity Type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:B
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:BROOKE DEE
Other - Last Name:HOLLAND
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1250 LAMOILLE HWY STE 103
Mailing Address - Street 2:
Mailing Address - City:ELKO
Mailing Address - State:NV
Mailing Address - Zip Code:89801-4397
Mailing Address - Country:US
Mailing Address - Phone:775-777-1292
Mailing Address - Fax:
Practice Address - Street 1:1250 LAMOILLE HWY STE 103
Practice Address - Street 2:
Practice Address - City:ELKO
Practice Address - State:NV
Practice Address - Zip Code:89801-4397
Practice Address - Country:US
Practice Address - Phone:775-777-1292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-11
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician