Provider Demographics
NPI:1457111320
Name:PETERSON, ANGELA LP (CMT)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:LP
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 1:188 ALTMAN CT
Mailing Address - Street 2:
Mailing Address - City:WEST SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55118-2501
Mailing Address - Country:US
Mailing Address - Phone:612-419-1121
Mailing Address - Fax:
Practice Address - Street 1:188 ALTMAN CT
Practice Address - Street 2:
Practice Address - City:WEST SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55118-2501
Practice Address - Country:US
Practice Address - Phone:612-419-1121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-19
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist