Provider Demographics
NPI:1073895090
Name:PETERSON, ELSA ELAINE (BA, QHMA)
Entity Type:Individual
Prefix:MS
First Name:ELSA
Middle Name:ELAINE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:BA, QHMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2175 NW IRVING ST
Mailing Address - Street 2:#3
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-3387
Mailing Address - Country:US
Mailing Address - Phone:503-866-6811
Mailing Address - Fax:
Practice Address - Street 1:2175 NW IRVING ST
Practice Address - Street 2:#3
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3387
Practice Address - Country:US
Practice Address - Phone:503-866-6811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-15
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health