Provider Demographics
NPI:1366235392
Name:PETERS, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:PETERS
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2067 ROAD 39 W
Mailing Address - Street 2:
Mailing Address - City:KIMBALL
Mailing Address - State:NE
Mailing Address - Zip Code:69145-9751
Mailing Address - Country:US
Mailing Address - Phone:970-302-7380
Mailing Address - Fax:
Practice Address - Street 1:1649 61ST ST
Practice Address - Street 2:STE 301 3RD FLOOR
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11204-3319
Practice Address - Country:US
Practice Address - Phone:970-302-7380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-23
Last Update Date:2025-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician