Provider Demographics
NPI:1649386053
Name:PETERSON, GERALYN EMMA (LMHC)
Entity Type:Individual
Prefix:
First Name:GERALYN
Middle Name:EMMA
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 19TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98371-7465
Mailing Address - Country:US
Mailing Address - Phone:253-770-8627
Mailing Address - Fax:253-770-8627
Practice Address - Street 1:521 19TH AVE SW
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98371-7465
Practice Address - Country:US
Practice Address - Phone:253-770-8627
Practice Address - Fax:253-770-8627
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00003497101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health