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General NPI Number Information
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NPI Number | 1861672966
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Entity Type | Individual
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Provider Name | MARCIE LYNN PETERSON
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Gender | Female
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Dates
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Enumeration Date | 11/07/2007
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Last Update Date | 11/07/2007
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Provider Practice Location Address
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Address Line | 659 N CITRUS AVE
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City | CRYSTAL RIVER
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State | FL
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Zip | 34428-3922
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Country | US
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Telephone | 352-563-0068
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Fax |
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Provider Business Mailing Address
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Address Line | 116 PINE ST
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City | HOMOSASSA
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State | FL
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Zip | 34446-4657
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Country | US
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Telephone | 352-228-1595
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | MA47512
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License Number State | FL
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