Provider Demographics
NPI:1245032002
Name:PETERS, ODESSA
Entity type:Individual
Prefix:
First Name:ODESSA
Middle Name:
Last Name:PETERS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3822 S EDMUNDS ST APT 2
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98118-1754
Mailing Address - Country:US
Mailing Address - Phone:414-238-4042
Mailing Address - Fax:
Practice Address - Street 1:3401 EVANSTON AVE N STE D
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103-8677
Practice Address - Country:US
Practice Address - Phone:425-880-4333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-25
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH61483137101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health