Provider Demographics
NPI:1396256772
Name:PETIT, CHRISTINA NOELLE BOSCOLO (LMT)
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:NOELLE BOSCOLO
Last Name:PETIT
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5109 137TH ST SE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-9536
Mailing Address - Country:US
Mailing Address - Phone:206-919-1537
Mailing Address - Fax:
Practice Address - Street 1:18021 15TH AVE NE STE 200
Practice Address - Street 2:
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98155-3806
Practice Address - Country:US
Practice Address - Phone:206-524-1330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-12
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60792019225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty