Provider Demographics
NPI:1710190426
Name:PETERSON HOUGEN, TRACI M (LMP)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:M
Last Name:PETERSON HOUGEN
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:TRACI
Other - Middle Name:M
Other - Last Name:HOUGEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMP
Mailing Address - Street 1:PO BOX 324
Mailing Address - Street 2:
Mailing Address - City:CONCONULLY
Mailing Address - State:WA
Mailing Address - Zip Code:98819-0324
Mailing Address - Country:US
Mailing Address - Phone:509-826-5548
Mailing Address - Fax:
Practice Address - Street 1:408 MAIN STREET
Practice Address - Street 2:
Practice Address - City:CONCONULLY
Practice Address - State:WA
Practice Address - Zip Code:98819
Practice Address - Country:US
Practice Address - Phone:509-826-5548
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00017693174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist