Provider Demographics
NPI:1487096012
Name:PETEFISH, KATHERINE A (LMSW, LCPC, BCBA LBA)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:A
Last Name:PETEFISH
Suffix:
Gender:F
Credentials:LMSW, LCPC, BCBA LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10719 BUCKEYE RD
Mailing Address - Street 2:
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-2960
Mailing Address - Country:US
Mailing Address - Phone:314-319-7098
Mailing Address - Fax:636-789-9062
Practice Address - Street 1:10719 BUCKEYE RD
Practice Address - Street 2:
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-2960
Practice Address - Country:US
Practice Address - Phone:314-319-7098
Practice Address - Fax:636-789-9062
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-24
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180009917101YP2500X
IA11517918103K00000X
IA008326104100000X
MO251S00000X
MO2015044940103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO730028185Medicaid