Healthcare Provider Details

I. General information

NPI: 1972271328
Provider Name (Legal Business Name): STEPHANIE LYN PETERSEN LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2021
Last Update Date: 09/01/2021
Certification Date: 08/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1412 YELM AVE E STE C101
YELM WA
98597-8328
US

IV. Provider business mailing address

PO BOX 674
RAINIER WA
98576-0674
US

V. Phone/Fax

Practice location:
  • Phone: 360-458-7533
  • Fax:
Mailing address:
  • Phone: 801-671-7221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00012013
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: