Provider Demographics
NPI:1174080550
Name:PETERS, LAURA LYNN
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:LYNN
Last Name:PETERS
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 1:14428 S VIA DEL MORO
Mailing Address - Street 2:
Mailing Address - City:SAHUARITA
Mailing Address - State:AZ
Mailing Address - Zip Code:85629-8453
Mailing Address - Country:US
Mailing Address - Phone:502-308-0517
Mailing Address - Fax:
Practice Address - Street 1:865 N DESERT BELL BLDG J
Practice Address - Street 2:
Practice Address - City:GREEN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85614-2558
Practice Address - Country:US
Practice Address - Phone:520-308-0715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-21
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-25581225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COMT.0019101OtherDORA
AZMT-25581OtherSTATE BOARD OF MASSEGE THERAPY