Provider Demographics
NPI:1275823361
Name:PETRICH, KAREN DIANE (LMP)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:DIANE
Last Name:PETRICH
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 1:7407 ELK CREEK LN
Mailing Address - Street 2:
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98335-8351
Mailing Address - Country:US
Mailing Address - Phone:253-857-8699
Mailing Address - Fax:
Practice Address - Street 1:6506 WOLLOCHET DR NW #B
Practice Address - Street 2:
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98335
Practice Address - Country:US
Practice Address - Phone:253-853-3353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-11
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60214292225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist