Provider Demographics
NPI:1760900765
Name:PETERS, MELISSA (MA 60691509)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:PETERS
Suffix:
Gender:F
Credentials:MA 60691509
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:823 W LARSON RD
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98226-9286
Mailing Address - Country:US
Mailing Address - Phone:406-209-5822
Mailing Address - Fax:360-392-6229
Practice Address - Street 1:823 W LARSON RD
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226
Practice Address - Country:US
Practice Address - Phone:360-746-1720
Practice Address - Fax:360-392-6229
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-30
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60691509225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist