Provider Demographics
NPI:1306694583
Name:PETERSON, KRISTIN (CDCA)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5760 PATRIOT BLVD
Mailing Address - Street 2:
Mailing Address - City:AUSTINTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44515-1170
Mailing Address - Country:US
Mailing Address - Phone:216-699-0473
Mailing Address - Fax:
Practice Address - Street 1:1500 MCKINLEY AVE
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:OH
Practice Address - Zip Code:44446-3718
Practice Address - Country:US
Practice Address - Phone:330-953-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-11
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH188238101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)