Healthcare Provider Details

I. General information

NPI: 1871516773
Provider Name (Legal Business Name): GLENDA A PETERSON PMHN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16110 SW REGATTA LN
BEAVERTON OR
97006-8942
US

IV. Provider business mailing address

PO BOX 42510
PORTLAND OR
97242-0510
US

V. Phone/Fax

Practice location:
  • Phone: 503-629-2131
  • Fax: 503-617-9379
Mailing address:
  • Phone: 503-963-1290
  • Fax: 503-230-1541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number079039861N6
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: