Provider Demographics
NPI:1992189328
Name:PETERSON, TIMOTHY JAMES (MA, LMHCA)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:JAMES
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MA, LMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25819 174TH ST SE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WA
Mailing Address - Zip Code:98272-9360
Mailing Address - Country:US
Mailing Address - Phone:732-233-1898
Mailing Address - Fax:
Practice Address - Street 1:25819 174TH ST SE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-9360
Practice Address - Country:US
Practice Address - Phone:732-233-1898
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-15
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC60568524101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMC 60568524OtherSTATE LICENSE