MEDICARE: STEPHANIE KAY PETERSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	3554-046	WI

General Provider Information

NPI Number	:	1427280882
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE KAY PETERSON

Provider Business Mailing Address
First Line	:	4330 GOLF TER
Second Line	:	SUITE 209
City	:	EAU CLAIRE
State	:	WI
Zip	:	54701-4683
Country	:	US
Telephone Number	:	715-835-1421
Fax Number	:

Provider Business Practice Location Address
First Line	:	4330 GOLF TER
Second Line	:	SUITE 209
City	:	EAU CLAIRE
State	:	WI
Zip	:	54701-4683
Country	:	US
Telephone Number	:	715-835-1421
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/19/2009
Last Update Date	:	08/19/2009

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