Healthcare Provider Details

I. General information

NPI: 1740149814
Provider Name (Legal Business Name): BRENNA PETERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2026
Last Update Date: 01/15/2026
Certification Date: 01/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 CALISTOGA ST W
ORTING WA
98360-2080
US

IV. Provider business mailing address

PO BOX 14
ORTING WA
98360-0014
US

V. Phone/Fax

Practice location:
  • Phone: 253-732-2290
  • Fax:
Mailing address:
  • Phone: 253-732-2290
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMASS.MA.70070764
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: