Basic Information
| Provider Information | |||||||||
| NPI: | 1902241888 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | KURT | ||||||||
| MiddleName: | |||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 230 W WELLS ST | ||||||||
| Address2: | ROOM 500 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532031866 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142900444 | ||||||||
| FaxNumber: | 4142260351 | ||||||||
| Practice Location | |||||||||
| Address1: | 230 W WELLS ST | ||||||||
| Address2: | ROOM 500 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532031866 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142900444 | ||||||||
| FaxNumber: | 4142260351 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2013 | ||||||||
| LastUpdateDate: | 05/06/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 4880-125 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.