Provider Demographics
NPI:1518023803
Name:PETERSEN, KATHLEEN GERYL (PHD)
Entity type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:GERYL
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7106 DALE AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HEIGHTS
Mailing Address - State:MO
Mailing Address - Zip Code:63117-1927
Mailing Address - Country:US
Mailing Address - Phone:314-647-5522
Mailing Address - Fax:314-827-0067
Practice Address - Street 1:7106 DALE AVENUE
Practice Address - Street 2:
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117-1927
Practice Address - Country:US
Practice Address - Phone:314-647-5522
Practice Address - Fax:314-827-0067
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOPYRO278103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000071251Medicare UPIN