Provider Demographics
NPI:1922358449
Name:PETERSON, ASTRID ELAINE (MA)
Entity Type:Individual
Prefix:MS
First Name:ASTRID
Middle Name:ELAINE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2214 E 13TH ST
Mailing Address - Street 2:MS: S-27
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-4120
Mailing Address - Country:US
Mailing Address - Phone:360-696-6321
Mailing Address - Fax:360-737-2120
Practice Address - Street 1:2214 E 13TH ST
Practice Address - Street 2:MS: S-27
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-4120
Practice Address - Country:US
Practice Address - Phone:360-696-6321
Practice Address - Fax:360-737-2120
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-12
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA324031D103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool