Healthcare Provider Details

I. General information

NPI: 1699244111
Provider Name (Legal Business Name): DAWN M PETERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2018
Last Update Date: 11/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 8TH ST
HOQUIAM WA
98550
US

IV. Provider business mailing address

PO BOX 1847
LONGVIEW WA
98632-8140
US

V. Phone/Fax

Practice location:
  • Phone: 360-532-4357
  • Fax: 360-577-0269
Mailing address:
  • Phone: 360-353-9828
  • Fax: 360-577-0269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: