Provider Demographics
NPI:1588133250
Name:PETERKIN, KEWASHAH N
Entity type:Individual
Prefix:MS
First Name:KEWASHAH
Middle Name:N
Last Name:PETERKIN
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 1:3915 CASCADE RD SW STE 250
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-8660
Mailing Address - Country:US
Mailing Address - Phone:678-561-0756
Mailing Address - Fax:
Practice Address - Street 1:3915 CASCADE RD SW STE 250
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-8660
Practice Address - Country:US
Practice Address - Phone:678-561-0756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-24
Last Update Date:2022-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC006199101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor