Provider Demographics
NPI:1063185064
Name:PETERSON, KAILEY LAPRES (LLMSW)
Entity type:Individual
Prefix:MRS
First Name:KAILEY
Middle Name:LAPRES
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 867
Mailing Address - Street 2:
Mailing Address - City:WHITE CLOUD
Mailing Address - State:MI
Mailing Address - Zip Code:49349-0867
Mailing Address - Country:US
Mailing Address - Phone:231-689-7330
Mailing Address - Fax:231-689-7345
Practice Address - Street 1:1049 E NEWELL ST
Practice Address - Street 2:
Practice Address - City:WHITE CLOUD
Practice Address - State:MI
Practice Address - Zip Code:49349-8795
Practice Address - Country:US
Practice Address - Phone:231-689-7330
Practice Address - Fax:231-689-7345
Is Sole Proprietor?:No
Enumeration Date:2021-07-27
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011077161041C0700X
MI68511077161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical