Provider Demographics
NPI:1790380012
Name:PETERSON, MEGAN E (CMT)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:E
Last Name:PETERSON
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2682C FREEDOM BLVD
Mailing Address - Street 2:
Mailing Address - City:WATSONVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95076-1066
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2682C FREEDOM BLVD
Practice Address - Street 2:
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076-1066
Practice Address - Country:US
Practice Address - Phone:831-207-7418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16552225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist