Provider Demographics
NPI:1952966038
Name:PETERSON, LAUREL (LMT)
Entity Type:Individual
Prefix:
First Name:LAUREL
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1024 STEPHENS AVE APT 10
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-3864
Mailing Address - Country:US
Mailing Address - Phone:585-738-9376
Mailing Address - Fax:
Practice Address - Street 1:1203 MOUNT AVE
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-5601
Practice Address - Country:US
Practice Address - Phone:406-543-5251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-05
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTLMT-LMT-LIC-6183225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist