Provider Demographics
NPI:1104383645
Name:PETERSEN, MARKELL (SUDP)
Entity type:Individual
Prefix:
First Name:MARKELL
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:SUDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2429
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-8486
Mailing Address - Country:US
Mailing Address - Phone:360-353-9494
Mailing Address - Fax:360-353-9440
Practice Address - Street 1:7700 NE 26TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98665-0672
Practice Address - Country:US
Practice Address - Phone:360-397-8228
Practice Address - Fax:360-397-8251
Is Sole Proprietor?:No
Enumeration Date:2019-02-20
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61146194101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)