Provider Demographics
NPI:1003364829
Name:PETERSON, REBECCA (CO 60202212)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:CO 60202212
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1178 SW LESCHI DR
Mailing Address - Street 2:
Mailing Address - City:OAK HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98277-5809
Mailing Address - Country:US
Mailing Address - Phone:360-672-0812
Mailing Address - Fax:
Practice Address - Street 1:5548 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:FREELAND
Practice Address - State:WA
Practice Address - Zip Code:98249-8776
Practice Address - Country:US
Practice Address - Phone:360-502-4090
Practice Address - Fax:425-249-3528
Is Sole Proprietor?:No
Enumeration Date:2016-09-21
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO 60202212101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)