Provider Demographics
NPI:1780797357
Name:PETERSON, MARYHELEN I (QMHP)
Entity type:Individual
Prefix:
First Name:MARYHELEN
Middle Name:I
Last Name:PETERSON
Suffix:
Gender:F
Credentials:QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48500 HWY 19
Mailing Address - Street 2:
Mailing Address - City:FOSSIL
Mailing Address - State:OR
Mailing Address - Zip Code:97830
Mailing Address - Country:US
Mailing Address - Phone:541-763-4315
Mailing Address - Fax:
Practice Address - Street 1:401 4TH STREET
Practice Address - Street 2:
Practice Address - City:FOSSIL
Practice Address - State:OR
Practice Address - Zip Code:97830
Practice Address - Country:US
Practice Address - Phone:541-763-2746
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselor
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional