1518265735 NPI number — MR. BRADLEY LEWIS PETERSON LMHC

Table of content: MR. BRADLEY LEWIS PETERSON LMHC (NPI 1518265735)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518265735 NPI number — MR. BRADLEY LEWIS PETERSON LMHC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSON
Provider First Name:
BRADLEY
Provider Middle Name:
LEWIS
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LMHC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1518265735
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/20/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11105 NE 14TH ST
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
VANCOUVER
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98684-4308
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-980-7906
Provider Business Mailing Address Fax Number:
360-326-1859

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11105 NE 14TH ST
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98684-4308
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-980-7906
Provider Business Practice Location Address Fax Number:
360-326-1859
Provider Enumeration Date:
03/11/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  LH60172629 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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