Provider Demographics
NPI:1063818409
Name:PETERSON, GREGORY HOWARD
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:HOWARD
Last Name:PETERSON
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 1:531 N HORNS CORNER DR
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD
Mailing Address - State:WA
Mailing Address - Zip Code:98642-8072
Mailing Address - Country:US
Mailing Address - Phone:253-691-6527
Mailing Address - Fax:
Practice Address - Street 1:1498 SE TECH CENTER PL STE 300
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-5509
Practice Address - Country:US
Practice Address - Phone:360-619-2226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-12
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC3885101YM0800X
WALH60514544101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health