Healthcare Provider Details

I. General information

NPI: 1619103736
Provider Name (Legal Business Name): CATHERINE ANN PETERSEN LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CATHERINE A NASH PETERSEN LMT, LLC

II. Dates (important events)

Enumeration Date: 06/03/2009
Last Update Date: 06/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9860 SW HALL BLVD
TIGARD OR
97223-8896
US

IV. Provider business mailing address

14215 SW YEARLING WAY
BEAVERTON OR
97008-6722
US

V. Phone/Fax

Practice location:
  • Phone: 503-806-6363
  • Fax:
Mailing address:
  • Phone: 503-806-6363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number6200
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: