Provider Demographics
NPI:1821474461
Name:PETERSON, KELLIE ALLISON (BCBA)
Entity Type:Individual
Prefix:MRS
First Name:KELLIE
Middle Name:ALLISON
Last Name:PETERSON
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 EAST ST APT 8
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MA
Mailing Address - Zip Code:01510-1737
Mailing Address - Country:US
Mailing Address - Phone:508-320-0582
Mailing Address - Fax:
Practice Address - Street 1:112 EAST ST APT 8
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MA
Practice Address - Zip Code:01510-1737
Practice Address - Country:US
Practice Address - Phone:508-320-0582
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-05
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA103103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst