Provider Demographics
NPI:1215243316
Name:PETERSON, HEATHER WEHLING
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:WEHLING
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
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 1729
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-1729
Mailing Address - Country:US
Mailing Address - Phone:503-692-8907
Mailing Address - Fax:503-612-0524
Practice Address - Street 1:19255 SW 65TH AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-7451
Practice Address - Country:US
Practice Address - Phone:503-692-8097
Practice Address - Fax:503-612-0524
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-26
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1059637225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1059637OtherSTATE LICENSE