Provider Demographics
NPI:1922752047
Name:PETERSON, DAKOTA JAMES (MT)
Entity type:Individual
Prefix:
First Name:DAKOTA
Middle Name:JAMES
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8335 N CONGRESS AVE
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64152-2041
Mailing Address - Country:US
Mailing Address - Phone:816-741-4711
Mailing Address - Fax:
Practice Address - Street 1:8335 N CONGRESS AVE
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64152-2041
Practice Address - Country:US
Practice Address - Phone:816-741-4711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-08
Last Update Date:2025-03-05
Deactivation Date:2024-12-16
Deactivation Code:
Reactivation Date:2025-01-28
Provider Licenses
StateLicense IDTaxonomies
MO2024008455225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist