Provider Demographics
NPI:1699039677
Name:PETERS, MOLLY PEARL OWEN (LMT)
Entity Type:Individual
Prefix:MS
First Name:MOLLY
Middle Name:PEARL OWEN
Last Name:PETERS
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 1:818 NW 17TH AVE
Mailing Address - Street 2:SUITE 6
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209
Mailing Address - Country:US
Mailing Address - Phone:651-307-2444
Mailing Address - Fax:
Practice Address - Street 1:818 NW 17TH AVE
Practice Address - Street 2:SUITE 6
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209
Practice Address - Country:US
Practice Address - Phone:651-307-2444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-25
Last Update Date:2017-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR18158225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist