Provider Demographics
NPI:1518289669
Name:PETERSEN, LINDSAY BEACH (NCMT)
Entity Type:Individual
Prefix:
First Name:LINDSAY
Middle Name:BEACH
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:NCMT
Other - Prefix:
Other - First Name:LINDSAY
Other - Middle Name:HUNTER
Other - Last Name:BEACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1 MERCADO ST
Mailing Address - Street 2:SUITE 150
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-7306
Mailing Address - Country:US
Mailing Address - Phone:970-375-2273
Mailing Address - Fax:970-375-2207
Practice Address - Street 1:1 MERCADO ST
Practice Address - Street 2:SUITE 150
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-7306
Practice Address - Country:US
Practice Address - Phone:970-375-2273
Practice Address - Fax:970-375-2207
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-17
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1438225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist