Provider Demographics
NPI: | 1659603686 |
---|---|
Name: | PETERSON, ROXANNE S (PHD, MSN, RN) |
Entity Type: | Individual |
Prefix: | |
First Name: | ROXANNE |
Middle Name: | S |
Last Name: | PETERSON |
Suffix: | |
Gender: | F |
Credentials: | PHD, MSN, RN |
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 97115 |
Mailing Address - Street 2: | |
Mailing Address - City: | LAKEWOOD |
Mailing Address - State: | WA |
Mailing Address - Zip Code: | 98497-0115 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 253-588-7911 |
Mailing Address - Fax: | 253-984-6774 |
Practice Address - Street 1: | 615 SHORT ST |
Practice Address - Street 2: | |
Practice Address - City: | STEILACOOM |
Practice Address - State: | WA |
Practice Address - Zip Code: | 98388-3115 |
Practice Address - Country: | US |
Practice Address - Phone: | 253-221-6789 |
Practice Address - Fax: | 253-584-8046 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2010-02-01 |
Last Update Date: | 2010-02-03 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
WA | LH | 101YM0800X |
WA | RN00063729 | 163W00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 101YM0800X | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No | 163W00000X | Nursing Service Providers | Registered Nurse |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
WA | RC00055688 | Other | LICENSE |
WA | RN00063729 | Other | LICENSE |
WA | LH60088357 | Other | LICENSE |