Provider Demographics
NPI:1770281115
Name:PETERSON, ANNA GRACE (CG 61390999)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:GRACE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:CG 61390999
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:SELAH
Mailing Address - State:WA
Mailing Address - Zip Code:98942-1667
Mailing Address - Country:US
Mailing Address - Phone:406-249-6556
Mailing Address - Fax:
Practice Address - Street 1:201 HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:BUENA
Practice Address - State:WA
Practice Address - Zip Code:98921-0139
Practice Address - Country:US
Practice Address - Phone:509-865-6705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-15
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG61390999101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA91-0755984Medicaid