Basic Information
| Provider Information | |||||||||
| NPI: | 1871516773 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | GLENDA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PMHN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 42510 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972420510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039631290 | ||||||||
| FaxNumber: | 5032301541 | ||||||||
| Practice Location | |||||||||
| Address1: | 16110 SW REGATTA LN | ||||||||
| Address2: | |||||||||
| City: | BEAVERTON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970068942 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036292131 | ||||||||
| FaxNumber: | 5036179379 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 079039861N6 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 115218 | 01 | MANAGED HEALTH | OTHER |