Basic Information
| Provider Information | |||||||||
| NPI: | 1659603686 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | ROXANNE | ||||||||
| MiddleName: | S | ||||||||
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| NameSuffix: | |||||||||
| Credential: | PHD, MSN, RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 97115 | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984970115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535887911 | ||||||||
| FaxNumber: | 2539846774 | ||||||||
| Practice Location | |||||||||
| Address1: | 615 SHORT ST | ||||||||
| Address2: | |||||||||
| City: | STEILACOOM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983883115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532216789 | ||||||||
| FaxNumber: | 2535848046 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2010 | ||||||||
| LastUpdateDate: | 02/03/2010 | ||||||||
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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 | 101YM0800X | LH | WA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health | 163W00000X | RN00063729 | WA | N | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | RC00055688 | 01 | WA | LICENSE | OTHER | RN00063729 | 01 | WA | LICENSE | OTHER | LH60088357 | 01 | WA | LICENSE | OTHER |