Provider Demographics
NPI:1104410216
Name:PETERSON SPORTS THERAPY LLC
Entity type:Organization
Organization Name:PETERSON SPORTS THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:M
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:978-774-4000
Mailing Address - Street 1:4 STATE RD
Mailing Address - Street 2:
Mailing Address - City:DANVERS
Mailing Address - State:MA
Mailing Address - Zip Code:01923-2567
Mailing Address - Country:US
Mailing Address - Phone:978-774-3400
Mailing Address - Fax:978-774-5883
Practice Address - Street 1:4 STATE RD
Practice Address - Street 2:
Practice Address - City:DANVERS
Practice Address - State:MA
Practice Address - Zip Code:01923-2567
Practice Address - Country:US
Practice Address - Phone:978-774-3400
Practice Address - Fax:978-774-5883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-01
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty