Provider Demographics
NPI:1730062571
Name:PETERSON, KOMEKIA
Entity type:Individual
Prefix:
First Name:KOMEKIA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:993 STOWELL DR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14616-1849
Mailing Address - Country:US
Mailing Address - Phone:585-698-4549
Mailing Address - Fax:585-698-4549
Practice Address - Street 1:993 STOWELL DR
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14616-1849
Practice Address - Country:US
Practice Address - Phone:585-698-4549
Practice Address - Fax:585-698-4549
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-29
Last Update Date:2025-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY34381101YA0400X
NY008405101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)