Provider Demographics
NPI:1104383645
Name:PETERSEN, MARKELL (CADC II)
Entity Type:Individual
Prefix:
First Name:MARKELL
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:CADC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 NW 5TH ST STE 202
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-1869
Mailing Address - Country:US
Mailing Address - Phone:541-504-2218
Mailing Address - Fax:
Practice Address - Street 1:340 NW 5TH ST STE 202
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-1869
Practice Address - Country:US
Practice Address - Phone:541-504-2218
Practice Address - Fax:541-320-9005
Is Sole Proprietor?:No
Enumeration Date:2019-02-20
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16-12-14101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)