Basic Information
| Provider Information | |||||||||
| NPI: | 1154891612 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | CHRISTINE | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19203 121ST PL SE | ||||||||
| Address2: | |||||||||
| City: | KENT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980310545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063729040 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1210 SW 136TH ST | ||||||||
| Address2: | |||||||||
| City: | BURIEN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981661214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062576734 | ||||||||
| FaxNumber: | 2062576825 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/27/2018 | ||||||||
| LastUpdateDate: | 11/27/2018 | ||||||||
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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 | 1041C0700X | LW60235824 | WA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.