Provider Demographics
NPI:1306844063
Name:PETERSON, BRUCE E (PT)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:E
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 9TH AVENUE
Mailing Address - Street 2:SUITE 220
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-2544
Mailing Address - Country:US
Mailing Address - Phone:360-578-1188
Mailing Address - Fax:360-578-6251
Practice Address - Street 1:625 9TH AVENUE
Practice Address - Street 2:SUITE 220
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2544
Practice Address - Country:US
Practice Address - Phone:360-578-1188
Practice Address - Fax:360-578-6251
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00002292225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA932823OtherFIRST HEALTH
WA8930118OtherCRIME VICTIMS
WAK465803OtherPACIFIC SOURCE
WA113275OtherKAISER PERMANENTE
WA179681OtherDEPARTMENT OF LABOR & IND
WA8345589Medicaid
WA8930118OtherCRIME VICTIMS