Provider Demographics
NPI:1447497110
Name:PETERSON, ANITRA BRINSON (LMT)
Entity type:Individual
Prefix:MS
First Name:ANITRA
Middle Name:BRINSON
Last Name:PETERSON
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 1:960 PHILLIPS DAIRY RD
Mailing Address - Street 2:
Mailing Address - City:TRYON
Mailing Address - State:NC
Mailing Address - Zip Code:28782-8707
Mailing Address - Country:US
Mailing Address - Phone:828-817-2695
Mailing Address - Fax:
Practice Address - Street 1:960 PHILLIPS DAIRY RD
Practice Address - Street 2:
Practice Address - City:TRYON
Practice Address - State:NC
Practice Address - Zip Code:28782-8707
Practice Address - Country:US
Practice Address - Phone:828-817-2695
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-16
Last Update Date:2009-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMAS5597225700000X
FLMA19613225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist