Provider Demographics
NPI:1053852905
Name:PETERSON, EVELYN BIRGITTA (LMT)
Entity Type:Individual
Prefix:MS
First Name:EVELYN
Middle Name:BIRGITTA
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 E 14TH AVE
Mailing Address - Street 2:8
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-4282
Mailing Address - Country:US
Mailing Address - Phone:801-688-0614
Mailing Address - Fax:
Practice Address - Street 1:405 E 14TH AVE
Practice Address - Street 2:8
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-4282
Practice Address - Country:US
Practice Address - Phone:801-688-0614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-11
Last Update Date:2017-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR22671225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist