Provider Demographics
NPI:1386387371
Name:PETERSEN, KATHRYN (LAC)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6730 E MCDOWELL RD STE 139
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85257-3135
Mailing Address - Country:US
Mailing Address - Phone:480-389-6971
Mailing Address - Fax:
Practice Address - Street 1:6730 E MCDOWELL RD STE 139
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85257-3135
Practice Address - Country:US
Practice Address - Phone:480-389-6971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-18
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-20231101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health