Provider Demographics
NPI:1447485594
Name:PETERCA, KRISTEN (MA, LPC, NCC)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:PETERCA
Suffix:
Gender:F
Credentials:MA, LPC, NCC
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 82819
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97282-0819
Mailing Address - Country:US
Mailing Address - Phone:503-233-5405
Mailing Address - Fax:503-233-2692
Practice Address - Street 1:1700 NW CIVIC DR
Practice Address - Street 2:SUITE 310
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3770
Practice Address - Country:US
Practice Address - Phone:503-666-8332
Practice Address - Fax:503-669-8641
Is Sole Proprietor?:No
Enumeration Date:2009-05-19
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC2304101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR164936Medicaid