Provider Demographics
NPI:1215301205
Name:PETERSON, KRISTIN ANN (MA LPC)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:ANN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MA LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11715 246TH CT
Mailing Address - Street 2:
Mailing Address - City:TREVOR
Mailing Address - State:WI
Mailing Address - Zip Code:53179-9229
Mailing Address - Country:US
Mailing Address - Phone:262-298-5335
Mailing Address - Fax:
Practice Address - Street 1:618 S IL ROUTE 31
Practice Address - Street 2:SUITE 2
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-8273
Practice Address - Country:US
Practice Address - Phone:815-344-9443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-14
Last Update Date:2015-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.010642101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional