Provider Demographics
NPI:1366812174
Name:KELLEY-PETERSEN, DANIEL (MAED, NCC, LMHC)
Entity type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:
Last Name:KELLEY-PETERSEN
Suffix:
Gender:M
Credentials:MAED, NCC, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2722 EASTLAKE AVE E
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98102-3143
Mailing Address - Country:US
Mailing Address - Phone:206-289-0281
Mailing Address - Fax:
Practice Address - Street 1:2722 EASTLAKE AVE E
Practice Address - Street 2:SUITE 300
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98102-3143
Practice Address - Country:US
Practice Address - Phone:206-289-0281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-06
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC60597324101YM0800X
WALH60738078101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health