Provider Demographics
NPI:1770817611
Name:PETERSON, CARY LEIGH (LMHC)
Entity Type:Individual
Prefix:MRS
First Name:CARY
Middle Name:LEIGH
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:MISS
Other - First Name:CARY
Other - Middle Name:LEIGH
Other - Last Name:FARR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 5127
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98206-5127
Mailing Address - Country:US
Mailing Address - Phone:425-258-3900
Mailing Address - Fax:
Practice Address - Street 1:4420 76TH ST NE
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98270-3726
Practice Address - Country:US
Practice Address - Phone:425-651-7490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-24
Last Update Date:2017-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH 60124112101YM0800X
WALW60750069104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2046876Medicaid