Provider Demographics
NPI:1427698729
Name:PETERSEN, SHANE
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5600 W 95TH ST STE 216
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66207-2968
Mailing Address - Country:US
Mailing Address - Phone:913-602-4039
Mailing Address - Fax:
Practice Address - Street 1:5600 W 95TH ST STE 216
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66207-2968
Practice Address - Country:US
Practice Address - Phone:913-602-4039
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-14
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS3123106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist