Provider Demographics
NPI:1972271328
Name:PETERSEN, STEPHANIE LYN (LMT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LYN
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 674
Mailing Address - Street 2:
Mailing Address - City:RAINIER
Mailing Address - State:WA
Mailing Address - Zip Code:98576-0674
Mailing Address - Country:US
Mailing Address - Phone:801-671-7221
Mailing Address - Fax:
Practice Address - Street 1:1412 YELM AVE E STE C101
Practice Address - Street 2:
Practice Address - City:YELM
Practice Address - State:WA
Practice Address - Zip Code:98597-8328
Practice Address - Country:US
Practice Address - Phone:360-458-7533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-01
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00012013225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty