Provider Demographics
NPI:1104229806
Name:PETERSEN, KRISTINA
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:PETERSEN
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 1:3450 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2331
Mailing Address - Country:US
Mailing Address - Phone:602-257-9339
Mailing Address - Fax:602-265-8533
Practice Address - Street 1:2580 HWAY 95 # 1250
Practice Address - Street 2:
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-7491
Practice Address - Country:US
Practice Address - Phone:928-763-7776
Practice Address - Fax:928-763-7786
Is Sole Proprietor?:No
Enumeration Date:2014-10-08
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ134391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZPENDINGMedicaid