Basic Information
| Provider Information | |||||||||
| NPI: | 1093432338 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | CADAC-II | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1027 E BURNSIDE ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972141328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032398400 | ||||||||
| FaxNumber: | 5032398407 | ||||||||
| Practice Location | |||||||||
| Address1: | 1427 SE 182ND AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972335008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037616006 | ||||||||
| FaxNumber: | 5037611434 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2022 | ||||||||
| LastUpdateDate: | 10/27/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 22-R-34 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.