Provider Demographics
NPI:1760789051
Name:PETERSON, TERRENCE (LMBT)
Entity Type:Individual
Prefix:MR
First Name:TERRENCE
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6508 WALSH BLVD
Mailing Address - Street 2:#D
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-8375
Mailing Address - Country:US
Mailing Address - Phone:704-540-4203
Mailing Address - Fax:
Practice Address - Street 1:6508 WALSH BLVD
Practice Address - Street 2:#D
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-8375
Practice Address - Country:US
Practice Address - Phone:704-540-4203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-22
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10618225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist