Healthcare Provider Details

I. General information

NPI: 1447929625
Provider Name (Legal Business Name): KATIE PETERS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2021
Last Update Date: 07/20/2022
Certification Date: 07/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1628 OKLAHOMA AVE
TRENTON MO
64683-2565
US

IV. Provider business mailing address

1601 OLD SOUTH RIVER RD
SAINT CHARLES MO
63303-4120
US

V. Phone/Fax

Practice location:
  • Phone: 660-359-4600
  • Fax:
Mailing address:
  • Phone: 636-224-1210
  • Fax: 636-246-1008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2021019454
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: