Provider Demographics
NPI:1063818409
Name:PETERSON, GREGORY HOWARD
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:HOWARD
Last Name:PETERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5926 SE 104TH AVE APT A
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-4184
Mailing Address - Country:US
Mailing Address - Phone:253-691-6527
Mailing Address - Fax:
Practice Address - Street 1:5926 SE 104TH AVE APT A
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-4184
Practice Address - Country:US
Practice Address - Phone:253-691-6527
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-12
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH60514544101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor