Healthcare Provider Details

I. General information

NPI: 1669510582
Provider Name (Legal Business Name): SUZANNE PETERSON LMFT, CADC-IT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 10/09/2025
Certification Date: 10/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 E JACKSON ST
MEDFORD OR
97504-6773
US

IV. Provider business mailing address

810 E JACKSON ST
MEDFORD OR
97504-6773
US

V. Phone/Fax

Practice location:
  • Phone: 541-500-7111
  • Fax: 541-507-9118
Mailing address:
  • Phone: 541-500-7111
  • Fax: 541-507-9118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberT1569
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: