Ethan David Pettyjohn, LPC

Primary specialty

Professional CounselorTaxonomy code 101YP2500X

License

C7752 Issued in OR

Practice address

9755 SW Barnes Rd
Portland, OR 97225-6651

Phone

(503) 444-4862

NPI assigned

Sep 27, 2018

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in OR

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Mental Health Counselor

Education

Other, 2018

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Telehealth

Offers telehealth services

Group practices

Western Psychological and Counseling Services LLCGroup PAC ID 7719975085, 331 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Western Psychological and Counseling Services LLC

  dba LifeStance Health

  • Clinical Psychologist
  • Tacoma, WA
  • NPI 1912008178

  Mental Health, OR

  Medicare reassignment Care Compare group NPD
• Western Psychological and Counseling Services LLC

  dba LifeStance Health

  • Clinical Psychologist
  • Vancouver, WA
  • NPI 1629345731

  Mental Health

  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1538006400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1699833600000",
    "number": "1619452307",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4370 SW 107TH AVE APT 4",
            "city": "BEAVERTON",
            "state": "OR",
            "postal_code": "970053187",
            "telephone_number": "978-621-4162"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "9755 SW BARNES RD",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972256651",
            "telephone_number": "503-444-4862"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PETTYJOHN",
        "first_name": "ETHAN",
        "middle_name": "DAVID",
        "credential": "LPC",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2018-09-27",
        "last_updated": "2023-11-13",
        "certification_date": "2023-11-13",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YP2500X",
            "taxonomy_group": "",
            "desc": "Counselor, Professional",
            "state": "OR",
            "license": "C7752",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Michelle Elizabeth Petty
• Randi Michelle Petty, RDH
• Terry Lee Petty, DC
• Pettygrove Dental LLC
• Pettygrove Physical Therpay Associates LLC
• Karen E Petzing, D.C.
• Lara Michelle Pevzner, M.A., LPC
• Brittany Pew, MS, OTR/L
• James A Peykanu, MD
• Douglas Lamonte Peyton II

• Professional Counselor in Portland, OR
• Providers in Portland, OR by specialty
• Professional Counselor in Oregon

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 13, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.