Provider Demographics
NPI:1942688544
Name:PETERS, CASEY LYNNE
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:LYNNE
Last Name:PETERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2139 WEST BURNSIDE ST APT 408
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210
Mailing Address - Country:US
Mailing Address - Phone:603-475-3470
Mailing Address - Fax:
Practice Address - Street 1:6040 SE BELMONT S
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97215
Practice Address - Country:US
Practice Address - Phone:603-475-3470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-14
Last Update Date:2015-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR340266225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist