Provider Demographics
NPI:1558417071
Name:PETERSON, KATHRYN LOUISE (LMP)
Entity Type:Individual
Prefix:MS
First Name:KATHRYN
Middle Name:LOUISE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2761
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98056-0761
Mailing Address - Country:US
Mailing Address - Phone:206-816-9807
Mailing Address - Fax:610-819-9807
Practice Address - Street 1:401 OLYMPIA AVE NE
Practice Address - Street 2:SUITE 213
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98056-4117
Practice Address - Country:US
Practice Address - Phone:206-816-9807
Practice Address - Fax:610-819-9807
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00020463225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist