Provider Demographics
NPI:1609186709
Name:PETERSON, PAMELA DIANE (LMT)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:DIANE
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 1:838 SW MORGAN WAY
Mailing Address - Street 2:
Mailing Address - City:TROUTDALE
Mailing Address - State:OR
Mailing Address - Zip Code:97060-1561
Mailing Address - Country:US
Mailing Address - Phone:503-706-8271
Mailing Address - Fax:
Practice Address - Street 1:1155 NE HOGAN DR
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-4129
Practice Address - Country:US
Practice Address - Phone:503-706-8271
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-07
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16817225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist