Provider Demographics
NPI:1306601695
Name:PETERSON, SUSAN KAY (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:KAY
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2849 MICHIGAN ST NE STE 100
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-1216
Mailing Address - Country:US
Mailing Address - Phone:616-956-0400
Mailing Address - Fax:
Practice Address - Street 1:2849 MICHIGAN ST NE STE 100
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-1216
Practice Address - Country:US
Practice Address - Phone:616-956-0400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-16
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501303188225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist