Provider Demographics
NPI:1871117275
Name:PETERSON, ALICIA ANN (LMT)
Entity type:Individual
Prefix:MRS
First Name:ALICIA
Middle Name:ANN
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:PO BOX 1503
Mailing Address - Street 2:
Mailing Address - City:MAKAWAO
Mailing Address - State:HI
Mailing Address - Zip Code:96768-9998
Mailing Address - Country:US
Mailing Address - Phone:415-306-3273
Mailing Address - Fax:
Practice Address - Street 1:291 HOOMAHA RD
Practice Address - Street 2:
Practice Address - City:MAKAWAO
Practice Address - State:HI
Practice Address - Zip Code:96768-8117
Practice Address - Country:US
Practice Address - Phone:415-306-3273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-01
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty