Provider Demographics
NPI:1689361503
Name:PETERSEN, SHEILA RUTH (CADC-R)
Entity Type:Individual
Prefix:
First Name:SHEILA
Middle Name:RUTH
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:CADC-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3955 SALMON RIVER HWY
Mailing Address - Street 2:
Mailing Address - City:OTIS
Mailing Address - State:OR
Mailing Address - Zip Code:97368-9778
Mailing Address - Country:US
Mailing Address - Phone:541-614-4437
Mailing Address - Fax:
Practice Address - Street 1:3955 SALMON RIVER HWY
Practice Address - Street 2:
Practice Address - City:OTIS
Practice Address - State:OR
Practice Address - Zip Code:97368-9778
Practice Address - Country:US
Practice Address - Phone:541-614-4437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-20
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT-23-2412101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)