Healthcare Provider Details

I. General information

NPI: 1447485594
Provider Name (Legal Business Name): KRISTEN PETERCA MA, LPC, NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2009
Last Update Date: 01/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 NW CIVIC DR SUITE 310
GRESHAM OR
97030-3770
US

IV. Provider business mailing address

PO BOX 82819
PORTLAND OR
97282-0819
US

V. Phone/Fax

Practice location:
  • Phone: 503-666-8332
  • Fax: 503-669-8641
Mailing address:
  • Phone: 503-233-5405
  • Fax: 503-233-2692

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC2304
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC2304
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: