Provider Demographics
NPI:1316260409
Name:PETERSON, DOREEN NICOSIA (OTR/L)
Entity type:Individual
Prefix:
First Name:DOREEN
Middle Name:NICOSIA
Last Name:PETERSON
Suffix:
Gender:F
Credentials:OTR/L
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 419
Mailing Address - Street 2:
Mailing Address - City:NEWTOWN SQUARE
Mailing Address - State:PA
Mailing Address - Zip Code:19073-0419
Mailing Address - Country:US
Mailing Address - Phone:610-356-7355
Mailing Address - Fax:610-355-7649
Practice Address - Street 1:100 MEDIA LINE RD
Practice Address - Street 2:
Practice Address - City:NEWTOWN SQUARE
Practice Address - State:PA
Practice Address - Zip Code:19073-4602
Practice Address - Country:US
Practice Address - Phone:610-356-7355
Practice Address - Fax:610-355-7649
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-04
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC007500L225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist