Provider Demographics
NPI:1669966446
Name:PETERSON, SUSAN CAROL (LMHC)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:CAROL
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1022
Mailing Address - Street 2:
Mailing Address - City:WINTHROP
Mailing Address - State:WA
Mailing Address - Zip Code:98862-1022
Mailing Address - Country:US
Mailing Address - Phone:509-341-4487
Mailing Address - Fax:
Practice Address - Street 1:105 NORFOLK RD
Practice Address - Street 2:
Practice Address - City:WINTHROP
Practice Address - State:WA
Practice Address - Zip Code:98862-4500
Practice Address - Country:US
Practice Address - Phone:509-341-4487
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-15
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH60824935101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health