Provider Demographics
NPI:1780414086
Name:PETERSON, KATHERINE FAY (PHD)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:FAY
Last Name:PETERSON
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 1:253 W BATTLE CREEK ST
Mailing Address - Street 2:
Mailing Address - City:GALESBURG
Mailing Address - State:MI
Mailing Address - Zip Code:49053-9675
Mailing Address - Country:US
Mailing Address - Phone:480-298-6451
Mailing Address - Fax:
Practice Address - Street 1:5500 ARMSTRONG RD
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49037-7314
Practice Address - Country:US
Practice Address - Phone:269-966-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-02
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301019526103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical