Provider Demographics
NPI:1184994360
Name:PETERSON, KREIG ROBERT (LMT, NCBTMB, MMT)
Entity type:Individual
Prefix:MR
First Name:KREIG
Middle Name:ROBERT
Last Name:PETERSON
Suffix:
Gender:M
Credentials:LMT, NCBTMB, MMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2075 WASMER CIR
Mailing Address - Street 2:
Mailing Address - City:BOSQUE FARMS
Mailing Address - State:NM
Mailing Address - Zip Code:87068-9683
Mailing Address - Country:US
Mailing Address - Phone:505-410-6161
Mailing Address - Fax:
Practice Address - Street 1:2075 WASMER CIR
Practice Address - Street 2:
Practice Address - City:BOSQUE FARMS
Practice Address - State:NM
Practice Address - Zip Code:87068-9683
Practice Address - Country:US
Practice Address - Phone:505-410-6161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-05
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM7114225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist