Healthcare Provider Details

I. General information

NPI: 1659615938
Provider Name (Legal Business Name): CARL V. PETERSON, PH.D., LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2012
Last Update Date: 11/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

286 E 18TH AVE
EUGENE OR
97401-4159
US

IV. Provider business mailing address

286 E 18TH AVE
EUGENE OR
97401-4159
US

V. Phone/Fax

Practice location:
  • Phone: 541-343-5501
  • Fax: 541-484-0416
Mailing address:
  • Phone: 541-343-5501
  • Fax: 541-484-0416

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number386
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number386
License Number StateOR

VII. Legacy identifiers

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

VIII. Authorized Official

Name: DR. CARL V. PETERSON
Title or Position: LICENSED PSYCHOLOGIST
Credential: PH.D.
Phone: 541-343-5501