Provider Demographics
NPI:1477827319
Name:PETERSON, LAURA MADELINE (LMT)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:MADELINE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:ANTOINE
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:708 ROUTE 134
Mailing Address - Street 2:SUITE 4
Mailing Address - City:SOUTH DENNIS
Mailing Address - State:MA
Mailing Address - Zip Code:02660-3062
Mailing Address - Country:US
Mailing Address - Phone:508-292-1014
Mailing Address - Fax:
Practice Address - Street 1:708 ROUTE 134
Practice Address - Street 2:SUITE 4
Practice Address - City:SOUTH DENNIS
Practice Address - State:MA
Practice Address - Zip Code:02660-3062
Practice Address - Country:US
Practice Address - Phone:508-292-1014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-23
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7787225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist