Provider Demographics
NPI:1164931648
Name:PETERSON, MOLLY CLAIRE (MS, OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:MOLLY
Middle Name:CLAIRE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:MISS
Other - First Name:MOLLY
Other - Middle Name:CLAIRE
Other - Last Name:BREWER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, OTR/L
Mailing Address - Street 1:25722 SE TIGER MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-8357
Mailing Address - Country:US
Mailing Address - Phone:336-504-3604
Mailing Address - Fax:
Practice Address - Street 1:32607 47TH AVE SW
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98023
Practice Address - Country:US
Practice Address - Phone:336-504-3604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-27
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60880652225X00000X
NC11335225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist