Provider Demographics
NPI:1245802693
Name:PETERS, PAUL JEROME (MSW, CSWA)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:JEROME
Last Name:PETERS
Suffix:
Gender:M
Credentials:MSW, CSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 NE RUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-3762
Mailing Address - Country:US
Mailing Address - Phone:971-268-8842
Mailing Address - Fax:
Practice Address - Street 1:333 NE RUSSELL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-3762
Practice Address - Country:US
Practice Address - Phone:971-268-8842
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-14
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health