Provider Demographics
NPI:1053527895
Name:PETERSON, KEVIN HOWARD (EDD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:HOWARD
Last Name:PETERSON
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12517 ELLIS RD NE
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21502-6876
Mailing Address - Country:US
Mailing Address - Phone:301-687-4389
Mailing Address - Fax:301-759-3360
Practice Address - Street 1:31 BALTIMORE ST
Practice Address - Street 2:SUITE 103
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-3024
Practice Address - Country:US
Practice Address - Phone:301-795-3360
Practice Address - Fax:301-759-3360
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2009-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD02746103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist