Provider Demographics
NPI:1275841462
Name:PETERSON, STEPHANIE J (LMT MA57965)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:J
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LMT MA57965
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 ALABAMA RD N STE 1
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33936-6829
Mailing Address - Country:US
Mailing Address - Phone:239-369-9986
Mailing Address - Fax:239-674-7645
Practice Address - Street 1:45 ALABAMA RD N STE 1
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33936-6829
Practice Address - Country:US
Practice Address - Phone:239-369-9986
Practice Address - Fax:239-674-7645
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-22
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA57965225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist