Provider Demographics
NPI:1982461497
Name:PETERSON, MAYA GRACE
Entity Type:Individual
Prefix:
First Name:MAYA
Middle Name:GRACE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9525 NE 7TH ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-3332
Mailing Address - Country:US
Mailing Address - Phone:360-608-9605
Mailing Address - Fax:
Practice Address - Street 1:9525 NE 7TH ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-3332
Practice Address - Country:US
Practice Address - Phone:360-608-9605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-01
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer