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
StateLicense IDTaxonomies
WALH101YM0800X
WARN00063729163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WARC00055688OtherLICENSE
WARN00063729OtherLICENSE
WALH60088357OtherLICENSE