Healthcare Provider Details

I. General information

NPI: 1235467168
Provider Name (Legal Business Name): BONNIE CELESTIA BUE-PETERSON LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2009
Last Update Date: 12/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3606 MAIN ST SUITE 205
VANCOUVER WA
98663-2257
US

IV. Provider business mailing address

3606 MAIN ST SUITE 205
VANCOUVER WA
98663-2257
US

V. Phone/Fax

Practice location:
  • Phone: 360-693-7781
  • Fax: 360-693-1688
Mailing address:
  • Phone: 360-639-7781
  • Fax: 360-693-1688

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA 60088320
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: