Provider Demographics
NPI:1477987113
Name:TAL, PETER VOM
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:VOM
Last Name:TAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:PEDRO
Other - Middle Name:
Other - Last Name:MEJIAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11576 SE 27TH AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-7719
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11576 SE 27TH AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-7719
Practice Address - Country:US
Practice Address - Phone:503-305-6943
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-29
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor