Provider Demographics
NPI:1407601644
Name:PETERSON, KATHY
Entity type:Individual
Prefix:
First Name:KATHY
Middle Name:
Last Name:PETERSON
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:N881 GROS CAP RD
Mailing Address - Street 2:
Mailing Address - City:SAINT IGNACE
Mailing Address - State:MI
Mailing Address - Zip Code:49781-9837
Mailing Address - Country:US
Mailing Address - Phone:906-643-8774
Mailing Address - Fax:906-984-2028
Practice Address - Street 1:PO BOX 307
Practice Address - Street 2:
Practice Address - City:SAINT IGNACE
Practice Address - State:MI
Practice Address - Zip Code:49781-0307
Practice Address - Country:US
Practice Address - Phone:906-643-8774
Practice Address - Fax:906-984-2028
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-22
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAS490300190320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities