Healthcare Provider Details

I. General information

NPI: 1053758417
Provider Name (Legal Business Name): ERIN PETTY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2013
Last Update Date: 05/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 NW WALLULA AVE
GRESHAM OR
97030-5455
US

IV. Provider business mailing address

801 NW WALLULA AVE
GRESHAM OR
97030-5455
US

V. Phone/Fax

Practice location:
  • Phone: 503-726-3800
  • Fax:
Mailing address:
  • Phone: 503-726-3800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: