Provider Demographics
NPI:1801039003
Name:PETERS, CORAL (LMP)
Entity type:Individual
Prefix:
First Name:CORAL
Middle Name:
Last Name:PETERS
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1607 S EVANS ST
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:WA
Mailing Address - Zip Code:98520-5114
Mailing Address - Country:US
Mailing Address - Phone:360-532-1093
Mailing Address - Fax:360-533-2058
Practice Address - Street 1:1033 1ST ST
Practice Address - Street 2:
Practice Address - City:COSMOPOLIS
Practice Address - State:WA
Practice Address - Zip Code:98520
Practice Address - Country:US
Practice Address - Phone:360-532-1093
Practice Address - Fax:360-533-2058
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-17
Last Update Date:2009-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60072538225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA60072538OtherWASHINGTON STATE LICENSE NUMBER