Provider Demographics
NPI:1932469228
Name:SANDERSON, PETER J (LMFT, MHP, CMHS)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:J
Last Name:SANDERSON
Suffix:
Gender:M
Credentials:LMFT, MHP, CMHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11834
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98508-1834
Mailing Address - Country:US
Mailing Address - Phone:360-402-0992
Mailing Address - Fax:
Practice Address - Street 1:2101 4TH AVE E
Practice Address - Street 2:SUITE 200
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-6512
Practice Address - Country:US
Practice Address - Phone:360-786-9499
Practice Address - Fax:360-786-0758
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-21
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALF60210516106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2021303Medicaid