Provider Demographics
NPI:1124596879
Name:KAUFFMAN, PETER
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:KAUFFMAN
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:PO BOX 724
Mailing Address - Street 2:
Mailing Address - City:FOSTER
Mailing Address - State:OR
Mailing Address - Zip Code:97345-0724
Mailing Address - Country:US
Mailing Address - Phone:541-409-1206
Mailing Address - Fax:
Practice Address - Street 1:1266 44TH AVE
Practice Address - Street 2:
Practice Address - City:SWEET HOME
Practice Address - State:OR
Practice Address - Zip Code:97386-1235
Practice Address - Country:US
Practice Address - Phone:541-409-1206
Practice Address - Fax:541-367-1995
Is Sole Proprietor?:No
Enumeration Date:2018-11-10
Last Update Date:2018-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORCO734101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health