Provider Demographics
NPI:1740019850
Name:PETERSON, LISA S (MT-BC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:S
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2623 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:FOREST GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97116-3003
Mailing Address - Country:US
Mailing Address - Phone:503-901-6953
Mailing Address - Fax:
Practice Address - Street 1:2623 12TH AVE
Practice Address - Street 2:
Practice Address - City:FOREST GROVE
Practice Address - State:OR
Practice Address - Zip Code:97116-3003
Practice Address - Country:US
Practice Address - Phone:503-901-6953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-29
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMT-T-10174257225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist