Provider Demographics
NPI:1326266560
Name:PETERSON, ATHENA (LMP)
Entity Type:Individual
Prefix:
First Name:ATHENA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:ATHENA
Other - Middle Name:
Other - Last Name:BOWER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMP
Mailing Address - Street 1:23100 PACIFIC HWY S
Mailing Address - Street 2:STE 201
Mailing Address - City:DES MOINES
Mailing Address - State:WA
Mailing Address - Zip Code:98198-7281
Mailing Address - Country:US
Mailing Address - Phone:206-824-9500
Mailing Address - Fax:206-824-9654
Practice Address - Street 1:23100 PACIFIC HWY S
Practice Address - Street 2:STE 201
Practice Address - City:DES MOINES
Practice Address - State:WA
Practice Address - Zip Code:98198-7281
Practice Address - Country:US
Practice Address - Phone:206-824-9500
Practice Address - Fax:206-824-9654
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00023839225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist