Provider Demographics
NPI:1356161921
Name:PETERSON, COLLEEN EMILY (LMT)
Entity type:Individual
Prefix:MRS
First Name:COLLEEN
Middle Name:EMILY
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 1:607 LANDEN DR
Mailing Address - Street 2:
Mailing Address - City:KALAMA
Mailing Address - State:WA
Mailing Address - Zip Code:98625-8918
Mailing Address - Country:US
Mailing Address - Phone:360-521-0679
Mailing Address - Fax:
Practice Address - Street 1:447 N 1ST ST STE 230
Practice Address - Street 2:
Practice Address - City:KALAMA
Practice Address - State:WA
Practice Address - Zip Code:98625-9105
Practice Address - Country:US
Practice Address - Phone:360-521-0679
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-16
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61584208225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist