Provider Demographics
NPI:1316350077
Name:PETERSON PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:PETERSON PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:410-371-0337
Mailing Address - Street 1:PO BOX 102
Mailing Address - Street 2:
Mailing Address - City:LA PLATA
Mailing Address - State:MD
Mailing Address - Zip Code:20646-0102
Mailing Address - Country:US
Mailing Address - Phone:301-539-3807
Mailing Address - Fax:301-539-3814
Practice Address - Street 1:144 DRURY DR
Practice Address - Street 2:
Practice Address - City:LA PLATA
Practice Address - State:MD
Practice Address - Zip Code:20646-4241
Practice Address - Country:US
Practice Address - Phone:410-371-0337
Practice Address - Fax:301-539-3814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-10
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD20342261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy