Provider Demographics
NPI:1538653951
Name:PETERSON, KAILA
Entity type:Individual
Prefix:
First Name:KAILA
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:PO BOX 128
Mailing Address - Street 2:
Mailing Address - City:WAUNA
Mailing Address - State:WA
Mailing Address - Zip Code:98395-0128
Mailing Address - Country:US
Mailing Address - Phone:208-656-5254
Mailing Address - Fax:
Practice Address - Street 1:708 BROADWAY STE 170
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-3778
Practice Address - Country:US
Practice Address - Phone:253-640-4049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-19
Last Update Date:2025-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMG60963154106H00000X
106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist