Provider Demographics
NPI:1952933244
Name:PETTERSON, KATHRYN ANN (PHD)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:ANN
Last Name:PETTERSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1241 BAYNES POINT DR
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-2848
Mailing Address - Country:US
Mailing Address - Phone:404-606-3247
Mailing Address - Fax:770-497-0130
Practice Address - Street 1:295 S CULVER ST STE D
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-3239
Practice Address - Country:US
Practice Address - Phone:770-995-5555
Practice Address - Fax:770-497-0130
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-05
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2113101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health