Provider Demographics
NPI:1518265735
Name:PETERSON, BRADLEY LEWIS (LMHC)
Entity Type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:LEWIS
Last Name:PETERSON
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11105 NE 14TH ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-4308
Mailing Address - Country:US
Mailing Address - Phone:360-980-7906
Mailing Address - Fax:360-326-1859
Practice Address - Street 1:11105 NE 14TH ST
Practice Address - Street 2:SUITE 103
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-4308
Practice Address - Country:US
Practice Address - Phone:360-980-7906
Practice Address - Fax:360-326-1859
Is Sole Proprietor?:No
Enumeration Date:2011-03-11
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH60172629101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health