Provider Demographics
NPI:1639720014
Name:PETERSON, KELLY ANN (MA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:844 CHURCH ST SW
Mailing Address - Street 2:
Mailing Address - City:HUTCHINSON
Mailing Address - State:MN
Mailing Address - Zip Code:55350-3004
Mailing Address - Country:US
Mailing Address - Phone:320-296-3087
Mailing Address - Fax:
Practice Address - Street 1:20288 HIGHWAY 15 N STE 100
Practice Address - Street 2:
Practice Address - City:HUTCHINSON
Practice Address - State:MN
Practice Address - Zip Code:55350-5685
Practice Address - Country:US
Practice Address - Phone:320-587-2326
Practice Address - Fax:320-234-6358
Is Sole Proprietor?:No
Enumeration Date:2019-09-26
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health