Basic Information
| Provider Information | |||||||||
| NPI: | 1003152521 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | LORI | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LMT, NCTMB | ||||||||
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| Mailing Information | |||||||||
| Address1: | 40707 N COURAGE TRL | ||||||||
| Address2: | |||||||||
| City: | ANTHEM | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850862531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6233634806 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 40707 N COURAGE TRL | ||||||||
| Address2: | |||||||||
| City: | ANTHEM | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850862531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6233634806 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2013 | ||||||||
| LastUpdateDate: | 01/02/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | MT-14879 | AZ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |
No ID Information.