Provider Demographics
NPI:1659629459
Name:PETERSON, DIANE LESLIE (LMP)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:LESLIE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1530 BELLEVUE WAY SE
Mailing Address - Street 2:SUITE C
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-7110
Mailing Address - Country:US
Mailing Address - Phone:425-818-0086
Mailing Address - Fax:425-818-5224
Practice Address - Street 1:1530 BELLEVUE WAY SE
Practice Address - Street 2:STE C
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-7110
Practice Address - Country:US
Practice Address - Phone:425-785-5608
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-27
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60129832225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist