Provider Demographics
NPI:1477327575
Name:PETERSON, PATRICE (LMT)
Entity Type:Individual
Prefix:MS
First Name:PATRICE
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 E TOPEKA DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85024-2225
Mailing Address - Country:US
Mailing Address - Phone:160-258-6672
Mailing Address - Fax:
Practice Address - Street 1:510 E TOPEKA DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85024-2225
Practice Address - Country:US
Practice Address - Phone:602-586-6729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-08
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-12874225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist