Provider Demographics
NPI:1427280882
Name:PETERSON, STEPHANIE KAY
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:KAY
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4330 GOLF TER
Mailing Address - Street 2:SUITE 209
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-4683
Mailing Address - Country:US
Mailing Address - Phone:715-835-1421
Mailing Address - Fax:
Practice Address - Street 1:4330 GOLF TER
Practice Address - Street 2:SUITE 209
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-4683
Practice Address - Country:US
Practice Address - Phone:715-835-1421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-19
Last Update Date:2009-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3554-046225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist