Provider Demographics
NPI:1861551293
Name:PETERSEN, MARK LINTON (MS)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:LINTON
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:M
Other - Middle Name:LINTON
Other - Last Name:PETERSEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS
Mailing Address - Street 1:12 BELLWETHER WAY STE 220
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-2914
Mailing Address - Country:US
Mailing Address - Phone:360-733-8157
Mailing Address - Fax:360-647-8336
Practice Address - Street 1:4545 CORDATA PKWY
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226-7123
Practice Address - Country:US
Practice Address - Phone:360-734-7310
Practice Address - Fax:360-647-8336
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00004491101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health