Healthcare Provider Details

I. General information

NPI: 1063818409
Provider Name (Legal Business Name): GREGORY HOWARD PETERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2014
Last Update Date: 04/24/2025
Certification Date: 04/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1498 SE TECH CENTER PL STE 300
VANCOUVER WA
98683-5509
US

IV. Provider business mailing address

531 N HORNS CORNER DR
RIDGEFIELD WA
98642-8072
US

V. Phone/Fax

Practice location:
  • Phone: 360-619-2226
  • Fax:
Mailing address:
  • Phone: 253-691-6527
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC3885
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLH60514544
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: