Healthcare Provider Details

I. General information

NPI: 1386314573
Provider Name (Legal Business Name): IVY LOUISE PETERSON EAST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2021
Last Update Date: 10/31/2021
Certification Date: 10/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1195A CITY VIEW ST
EUGENE OR
97402-3325
US

IV. Provider business mailing address

4750 FRANKLIN BLVD SPC B5
EUGENE OR
97403-2450
US

V. Phone/Fax

Practice location:
  • Phone: 541-357-6389
  • Fax:
Mailing address:
  • Phone: 458-239-3345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: