Healthcare Provider Details

I. General information

NPI: 1689579625
Provider Name (Legal Business Name): MRS. TABBETHA ANN CLOUSE-PETERO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2026
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2141 3RD AVE E
KALISPELL MT
59901-5761
US

IV. Provider business mailing address

PO BOX 1966
COLUMBIA FALLS MT
59912-1966
US

V. Phone/Fax

Practice location:
  • Phone: 406-885-2231
  • Fax:
Mailing address:
  • Phone: 406-885-2231
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberLMT-LMT-LIC-34355
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: