Provider Demographics
NPI:1598199622
Name:PETERSON, ALICE WASHINGTON (LMT)
Entity Type:Individual
Prefix:MRS
First Name:ALICE
Middle Name:WASHINGTON
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 1:202 WILLIAMSBURG AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:SC
Mailing Address - Zip Code:29560-2736
Mailing Address - Country:US
Mailing Address - Phone:843-598-2905
Mailing Address - Fax:
Practice Address - Street 1:148 SAULS ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:SC
Practice Address - Zip Code:29560-2631
Practice Address - Country:US
Practice Address - Phone:843-374-4433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-26
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8484225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist