Provider Demographics
NPI:1427711779
Name:PETERSON, KHALISHA M
Entity type:Individual
Prefix:
First Name:KHALISHA
Middle Name:M
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 1:166 KAYDON DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-5336
Mailing Address - Country:US
Mailing Address - Phone:217-904-0102
Mailing Address - Fax:
Practice Address - Street 1:309 WALNUT ST
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-2767
Practice Address - Country:US
Practice Address - Phone:703-564-1634
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-14
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician