Basic Information
| Provider Information | |||||||||
| NPI: | 1538228051 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | E | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 84646 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981245946 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1809 COOKS HILL RD | ||||||||
| Address2: | |||||||||
| City: | CENTRALIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985319072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603308626 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT00003655 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 4837PE | 01 | WA | REGENCE | OTHER | PT00003655 | 01 | WA | LICENSE NUMBER | OTHER | 8342693 | 05 | WA | MEDICAID | 201107 | 01 | WA | L & I | OTHER |