Provider Demographics
NPI:1538533393
Name:PETERSON, KEVIN (HHC, LMT)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:HHC, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 EVERGREEN DR APT 200C
Mailing Address - Street 2:
Mailing Address - City:WAUKEE
Mailing Address - State:IA
Mailing Address - Zip Code:50263-8724
Mailing Address - Country:US
Mailing Address - Phone:515-829-9477
Mailing Address - Fax:
Practice Address - Street 1:6989 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:WINDSOR HEIGHTS
Practice Address - State:IA
Practice Address - Zip Code:50324-1540
Practice Address - Country:US
Practice Address - Phone:515-829-9477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-17
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA004782225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist