Provider Demographics
NPI:1316572829
Name:PETRIE, EILEEN GWENDOLYN (CDPT)
Entity Type:Individual
Prefix:
First Name:EILEEN
Middle Name:GWENDOLYN
Last Name:PETRIE
Suffix:
Gender:F
Credentials:CDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30620 PACIFIC HWY S STE 107
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-4888
Mailing Address - Country:US
Mailing Address - Phone:253-941-7555
Mailing Address - Fax:253-941-0652
Practice Address - Street 1:30620 PACIFIC HWY S STE 107
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-4888
Practice Address - Country:US
Practice Address - Phone:253-941-7555
Practice Address - Fax:253-941-0652
Is Sole Proprietor?:No
Enumeration Date:2020-03-04
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60371115390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program