Provider Demographics
NPI:1285796268
Name:PETERSON, PENNY (PTA)
Entity type:Individual
Prefix:
First Name:PENNY
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
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:W7812 AMSTERDAM PRAIRIE RD
Mailing Address - Street 2:
Mailing Address - City:HOLMEN
Mailing Address - State:WI
Mailing Address - Zip Code:54636-9394
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:713 N LEONARD ST
Practice Address - Street 2:
Practice Address - City:WEST SALEM
Practice Address - State:WI
Practice Address - Zip Code:54669-1229
Practice Address - Country:US
Practice Address - Phone:608-786-2274
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI60-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant