Provider Demographics
NPI:1619103736
Name:PETERSEN, CATHERINE ANN (LMT)
Entity Type:Individual
Prefix:
First Name:CATHERINE
Middle Name:ANN
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:CATHERINE
Other - Middle Name:A NASH
Other - Last Name:PETERSEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT, LLC
Mailing Address - Street 1:14215 SW YEARLING WAY
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97008-6722
Mailing Address - Country:US
Mailing Address - Phone:503-806-6363
Mailing Address - Fax:
Practice Address - Street 1:9860 SW HALL BLVD
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-8896
Practice Address - Country:US
Practice Address - Phone:503-806-6363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-03
Last Update Date:2009-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6200225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist