Provider Demographics
NPI:1487803110
Name:PETERSON, LISE ANNE
Entity type:Individual
Prefix:
First Name:LISE
Middle Name:ANNE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42343 47TH ST WEST
Mailing Address - Street 2:
Mailing Address - City:QUARTZ HILL
Mailing Address - State:CA
Mailing Address - Zip Code:93536
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:815 W LANCASTER BLVD STE 15
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-2303
Practice Address - Country:US
Practice Address - Phone:661-916-8950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-18
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner