Provider Demographics
NPI:1073644969
Name:PETERSON, LISE MARY (LMP)
Entity Type:Individual
Prefix:MS
First Name:LISE
Middle Name:MARY
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17401 135TH AVE NE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:WOODINVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98072-6825
Mailing Address - Country:US
Mailing Address - Phone:425-483-5454
Mailing Address - Fax:425-424-3256
Practice Address - Street 1:17401 135TH AVE NE
Practice Address - Street 2:SUITE 4
Practice Address - City:WOODINVILLE
Practice Address - State:WA
Practice Address - Zip Code:98072-6825
Practice Address - Country:US
Practice Address - Phone:425-483-5454
Practice Address - Fax:425-424-3256
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00012465174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist