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General NPI Number Information
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NPI Number | 1386403863
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Entity Type | Individual
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Provider Name | CAROLYN ALISA PETERSON PHD
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Gender | Female
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Dates
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Enumeration Date | 03/18/2024
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Last Update Date | 01/25/2025
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Provider Practice Location Address
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Address Line | 4039 N MISSISSIPPI AVE STE 307
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City | PORTLAND
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State | OR
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Zip | 97227-1477
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Country | US
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Telephone | 971-402-9705
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Fax |
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Provider Business Mailing Address
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Address Line | 4039 N MISSISSIPPI AVE STE 307
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City | PORTLAND
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State | OR
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Zip | 97227-1477
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Country | US
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Telephone | 971-402-9705
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 3197
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License Number State | OR
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