Provider Demographics
NPI:1669510582
Name:PETERSON, SUZANNE (LMFT, CADC-IT)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LMFT, CADC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7667
Mailing Address - Country:US
Mailing Address - Phone:541-842-7705
Mailing Address - Fax:541-842-7640
Practice Address - Street 1:900 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7136
Practice Address - Country:US
Practice Address - Phone:541-842-7705
Practice Address - Fax:541-842-7640
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500738443Medicaid