Provider Demographics
NPI:1174572846
Name:PETERSON, MARY E (MD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:E
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 W 8TH AVE STE 6055
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-2312
Mailing Address - Country:US
Mailing Address - Phone:509-455-9090
Mailing Address - Fax:
Practice Address - Street 1:105 W 8TH AVE STE 6055
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2312
Practice Address - Country:US
Practice Address - Phone:509-455-9090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI460802084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry