Provider Demographics
NPI:1659615938
Name:CARL V. PETERSON, PH.D., LLC
Entity Type:Organization
Organization Name:CARL V. PETERSON, PH.D., LLC
Other - Org Name:CARL V. PETERSON, PH.D.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:V
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:541-343-5501
Mailing Address - Street 1:286 E 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-4159
Mailing Address - Country:US
Mailing Address - Phone:541-343-5501
Mailing Address - Fax:541-484-0416
Practice Address - Street 1:286 E 18TH AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-4159
Practice Address - Country:US
Practice Address - Phone:541-343-5501
Practice Address - Fax:541-484-0416
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-26
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR386261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health