Provider Demographics
NPI:1699244111
Name:PETERSON, DAWN M
Entity type:Individual
Prefix:
First Name:DAWN
Middle Name:M
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 1847
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-8140
Mailing Address - Country:US
Mailing Address - Phone:360-353-9828
Mailing Address - Fax:360-577-0269
Practice Address - Street 1:615 8TH ST
Practice Address - Street 2:
Practice Address - City:HOQUIAM
Practice Address - State:WA
Practice Address - Zip Code:98550
Practice Address - Country:US
Practice Address - Phone:360-532-4357
Practice Address - Fax:360-577-0269
Is Sole Proprietor?:No
Enumeration Date:2018-11-14
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA175T00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2113068Medicaid