Provider Demographics
NPI:1649921362
Name:PETERSEN, KAYLA (LPC)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:LPC
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 19070
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54307-9070
Mailing Address - Country:US
Mailing Address - Phone:920-496-4700
Mailing Address - Fax:
Practice Address - Street 1:715 DECORAH RD
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-8112
Practice Address - Country:US
Practice Address - Phone:715-651-1368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-13
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5196226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional