Basic Information
Provider Information
NPI: 1003155987
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: PETERS
FirstName: KELLY
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: OT
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 500 CROSS ST
Address2:  
City: BIG STONE CITY
State: SD
PostalCode: 572168237
CountryCode: US
TelephoneNumber: 6055411140
FaxNumber: 6055410109
Practice Location
Address1: 8 5TH ST SE
Address2:  
City: WATERTOWN
State: SD
PostalCode: 572013713
CountryCode: US
TelephoneNumber: 6057535400
FaxNumber: 3208394196
Other Information
ProviderEnumerationDate: 02/12/2013
LastUpdateDate: 08/28/2019
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225X00000X0870SDY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist 

No ID Information.


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