Provider Demographics
NPI:1225433956
Name:PETERSEN, LORI
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:PETERSEN
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:PO BOX 2145
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99210-2145
Mailing Address - Country:US
Mailing Address - Phone:509-953-1000
Mailing Address - Fax:509-458-6087
Practice Address - Street 1:518 S 13TH ST
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-3919
Practice Address - Country:US
Practice Address - Phone:509-953-1000
Practice Address - Fax:509-458-6087
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-23
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator