Basic Information
| Provider Information | |||||||||
| NPI: | 1073796173 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TELLER | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | WAYNE | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 305 WALNUT WAY | ||||||||
| Address2: | |||||||||
| City: | SILVERTON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973812419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038730703 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1073 OAK ST SE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973014018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035854949 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2007 | ||||||||
| LastUpdateDate: | 10/04/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.