Provider Demographics
NPI:1760701676
Name:PETERSON, LIBBY L (LMP)
Entity Type:Individual
Prefix:MRS
First Name:LIBBY
Middle Name:L
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 1:10785 LONE PINE DR
Mailing Address - Street 2:
Mailing Address - City:LEAVENWORTH
Mailing Address - State:WA
Mailing Address - Zip Code:98826-9027
Mailing Address - Country:US
Mailing Address - Phone:509-881-4329
Mailing Address - Fax:509-548-8401
Practice Address - Street 1:10090 MAIN ST
Practice Address - Street 2:SUITE G
Practice Address - City:PESHASTIN
Practice Address - State:WA
Practice Address - Zip Code:98847-9770
Practice Address - Country:US
Practice Address - Phone:509-881-4329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-18
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60160288225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist