Provider Demographics
NPI:1285906321
Name:PETERSON, MICHAEL (MS, ATC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4021 ANNE MARIE AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68803-9702
Mailing Address - Country:US
Mailing Address - Phone:815-712-7636
Mailing Address - Fax:
Practice Address - Street 1:620 N DIERS AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-4984
Practice Address - Country:US
Practice Address - Phone:308-382-0344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-06
Last Update Date:2014-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0024112255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer