Provider Demographics
NPI:1003647959
Name:PETERSON, GRACE KATHERINE (LMLP-T)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:KATHERINE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LMLP-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17630 W 83RD TER
Mailing Address - Street 2:
Mailing Address - City:LENEXA
Mailing Address - State:KS
Mailing Address - Zip Code:66219-8141
Mailing Address - Country:US
Mailing Address - Phone:913-617-6953
Mailing Address - Fax:
Practice Address - Street 1:7501 COLLEGE BLVD STE 250
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66210-2505
Practice Address - Country:US
Practice Address - Phone:913-451-8550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-12
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS03326-T103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical