Provider Demographics
NPI:1013108349
Name:PETERSEN-TETZ, SANDRA ANNE (CADC I)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:ANNE
Last Name:PETERSEN-TETZ
Suffix:
Gender:F
Credentials:CADC I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT HELENS
Mailing Address - State:OR
Mailing Address - Zip Code:97051-1535
Mailing Address - Country:US
Mailing Address - Phone:503-366-4540
Mailing Address - Fax:503-366-4526
Practice Address - Street 1:185 N 4TH ST
Practice Address - Street 2:
Practice Address - City:SAINT HELENS
Practice Address - State:OR
Practice Address - Zip Code:97051-1535
Practice Address - Country:US
Practice Address - Phone:503-366-4540
Practice Address - Fax:503-366-4526
Is Sole Proprietor?:No
Enumeration Date:2007-08-01
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR98-04-29101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor