Provider Demographics
NPI:1134510316
Name:PETERSEN, MARLYS ANN (MA)
Entity Type:Individual
Prefix:
First Name:MARLYS
Middle Name:ANN
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:MA
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 80524
Mailing Address - Street 2:SW PICASSO PLACE
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97280-1524
Mailing Address - Country:US
Mailing Address - Phone:503-867-9913
Mailing Address - Fax:
Practice Address - Street 1:8325 SW 61ST AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-3109
Practice Address - Country:US
Practice Address - Phone:503-867-9913
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-10
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health