Provider Demographics
NPI:1134594583
Name:PETERSON, KRISTEN NOEL
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:NOEL
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6655 W SAHARA AVE STE D110
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-0846
Mailing Address - Country:US
Mailing Address - Phone:702-365-0600
Mailing Address - Fax:
Practice Address - Street 1:5915 S RAINBOW BLVD STE 105
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89118
Practice Address - Country:US
Practice Address - Phone:702-209-0370
Practice Address - Fax:702-405-0935
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-10
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVMI0861106H00000X
390200000X
NV3071106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program