Provider Demographics
NPI:1720135163
Name:PETERSON, MARY (PHD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 HILLTOP DR
Mailing Address - Street 2:
Mailing Address - City:NEWBERG
Mailing Address - State:OR
Mailing Address - Zip Code:97132-9027
Mailing Address - Country:US
Mailing Address - Phone:503-538-2831
Mailing Address - Fax:
Practice Address - Street 1:414 N MERIDIAN ST
Practice Address - Street 2:BOX 6275
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132-2697
Practice Address - Country:US
Practice Address - Phone:503-554-2377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1671103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical