Provider Demographics
NPI:1083338321
Name:PETERSON, KEISHA MICHELLE
Entity type:Individual
Prefix:MRS
First Name:KEISHA
Middle Name:MICHELLE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 PLAZA DRIVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95765
Mailing Address - Country:US
Mailing Address - Phone:888-568-2494
Mailing Address - Fax:
Practice Address - Street 1:209 PLAZA DRIVE
Practice Address - Street 2:SUITE 100
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95765
Practice Address - Country:US
Practice Address - Phone:888-568-2494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-29
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician