Provider Demographics
NPI:1457809717
Name:PETERSON, KRISTINE NOER (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KRISTINE
Middle Name:NOER
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:KRISTINE
Other - Middle Name:NOER
Other - Last Name:MAKHAMREH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1032 CROSSWINDS CT
Mailing Address - Street 2:
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385-4836
Mailing Address - Country:US
Mailing Address - Phone:636-332-6000
Mailing Address - Fax:
Practice Address - Street 1:1032 CROSSWINDS CT
Practice Address - Street 2:
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-4836
Practice Address - Country:US
Practice Address - Phone:636-332-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-15
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016035945103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical