Provider Demographics
NPI:1184200123
Name:PETERSON, TREONNA L
Entity Type:Individual
Prefix:
First Name:TREONNA
Middle Name:L
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 FAWCETT AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-5502
Mailing Address - Country:US
Mailing Address - Phone:253-383-3971
Mailing Address - Fax:
Practice Address - Street 1:721 FAWCETT AVE STE 101
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-5502
Practice Address - Country:US
Practice Address - Phone:253-383-3971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-21
Last Update Date:2021-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPETERTL092M8OtherWASHINGTON STATE IDENTIFICATION CARD