Provider Demographics
NPI:1215457601
Name:PETERSEN, CODY (PTA)
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 S 34TH ST
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-6057
Mailing Address - Country:US
Mailing Address - Phone:360-927-2203
Mailing Address - Fax:
Practice Address - Street 1:316 E MCLEOD RD STE 101
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226-6491
Practice Address - Country:US
Practice Address - Phone:360-734-5410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-26
Last Update Date:2017-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60045899225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant