Provider Demographics
NPI:1841805959
Name:CHESNUT-PETRY, KORBEN J (CADC 1)
Entity Type:Individual
Prefix:
First Name:KORBEN
Middle Name:J
Last Name:CHESNUT-PETRY
Suffix:
Gender:M
Credentials:CADC 1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1160 LIBERTY ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-4143
Mailing Address - Country:US
Mailing Address - Phone:503-391-9762
Mailing Address - Fax:
Practice Address - Street 1:1325 COMMERCIAL ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4205
Practice Address - Country:US
Practice Address - Phone:971-301-9574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-15
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR18-02-03101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty