Provider Demographics
NPI:1649403460
Name:PETERSON, RAYMOND W (PHD, LPC)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:W
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PHD, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2149 CASCADE AVE
Mailing Address - Street 2:106A-44
Mailing Address - City:HOOD RIVER
Mailing Address - State:OR
Mailing Address - Zip Code:97031-1087
Mailing Address - Country:US
Mailing Address - Phone:503-223-7719
Mailing Address - Fax:503-255-4714
Practice Address - Street 1:8035 NE PRESCOTT ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97218-4249
Practice Address - Country:US
Practice Address - Phone:503-223-7719
Practice Address - Fax:503-255-4714
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-27
Last Update Date:2009-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC0457101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health