Provider Demographics
NPI:1629599196
Name:THERESA PETERS COUNSELING LLC
Entity Type:Organization
Organization Name:THERESA PETERS COUNSELING LLC
Other - Org Name:THERESA PETERS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:LICENCED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:503-437-4595
Mailing Address - Street 1:6023 ANGLE DR NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97317-2327
Mailing Address - Country:US
Mailing Address - Phone:503-437-4595
Mailing Address - Fax:
Practice Address - Street 1:805 LIBERTY ST NE STE 2
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-2463
Practice Address - Country:US
Practice Address - Phone:503-437-4595
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THERESA PETERS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-07-05
Last Update Date:2017-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL6571104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty