Provider Demographics
NPI:1215924279
Name:PETERSON, JULIE (PT)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4828
Mailing Address - Street 2:
Mailing Address - City:EDWARDS
Mailing Address - State:CO
Mailing Address - Zip Code:81632-4828
Mailing Address - Country:US
Mailing Address - Phone:970-569-3883
Mailing Address - Fax:970-569-3884
Practice Address - Street 1:1140 EDWARDS VILLAGE BLVD B208
Practice Address - Street 2:
Practice Address - City:EDWARDS
Practice Address - State:CO
Practice Address - Zip Code:81632-4828
Practice Address - Country:US
Practice Address - Phone:970-569-3883
Practice Address - Fax:970-569-3884
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO91112251X0800X
CO1161230225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCO303708Medicare PIN
COC810751Medicare PIN
COC0307543Medicare PIN