Provider Demographics
NPI:1932398716
Name:PETERSEN, TRISTA JEAN (LMP)
Entity Type:Individual
Prefix:MISS
First Name:TRISTA
Middle Name:JEAN
Last Name:PETERSEN
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:PO BOX 97297
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98497-0297
Mailing Address - Country:US
Mailing Address - Phone:253-507-2858
Mailing Address - Fax:
Practice Address - Street 1:8509 STEILACOOM BLVD SW STE D
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98498-4786
Practice Address - Country:US
Practice Address - Phone:253-507-2858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-17
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00023763225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist