Provider Demographics
NPI:1316158777
Name:PETERSON, BRIAN EUGENE (LPTA)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:EUGENE
Last Name:PETERSON
Suffix:
Gender:M
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4980 SW 195TH AVE
Mailing Address - Street 2:
Mailing Address - City:DUNNELLON
Mailing Address - State:FL
Mailing Address - Zip Code:34431
Mailing Address - Country:US
Mailing Address - Phone:352-465-7833
Mailing Address - Fax:
Practice Address - Street 1:12139 S. WILLIAMS ST
Practice Address - Street 2:
Practice Address - City:DUNELLON
Practice Address - State:FL
Practice Address - Zip Code:34431
Practice Address - Country:US
Practice Address - Phone:352-489-2500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA 17956225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant