Provider Demographics
NPI:1093098170
Name:PETERSON, COLLETTE KAE (CMT)
Entity Type:Individual
Prefix:MS
First Name:COLLETTE
Middle Name:KAE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:MS
Other - First Name:COLLETTE
Other - Middle Name:KAE
Other - Last Name:KLINKOPF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CMT
Mailing Address - Street 1:31480 BROOKLINE RD
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN
Mailing Address - State:CO
Mailing Address - Zip Code:80439-8946
Mailing Address - Country:US
Mailing Address - Phone:303-928-9860
Mailing Address - Fax:
Practice Address - Street 1:31480 BROOKLINE RD
Practice Address - Street 2:
Practice Address - City:EVERGREEN
Practice Address - State:CO
Practice Address - Zip Code:80439-8946
Practice Address - Country:US
Practice Address - Phone:303-928-9860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-24
Last Update Date:2011-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2564225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist