=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053681452
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LUCY ROSE PETERSON CADC II
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2012
-----------------------------------------------------
Last Update Date | 09/10/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17645 NW SAINT HELENS RD
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97231-1729
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-621-1069
-----------------------------------------------------
Fax | 503-621-0200
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1776 SW MADISON ST
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97205-1715
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-224-1044
-----------------------------------------------------
Fax | 503-621-2235
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 11807
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 00-03-32
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------