Provider Demographics
NPI:1053785931
Name:PETERSON, FAWNE (MT)
Entity type:Individual
Prefix:
First Name:FAWNE
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44191 PLYMOUTH OAKS BLVD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-6530
Mailing Address - Country:US
Mailing Address - Phone:734-259-7103
Mailing Address - Fax:
Practice Address - Street 1:44191 PLYMOUTH OAKS BLVD
Practice Address - Street 2:SUITE 400
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-6530
Practice Address - Country:US
Practice Address - Phone:734-259-7103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-16
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501002781225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist