Provider Demographics
NPI:1528704806
Name:PETERSON, RONDALE (PTA)
Entity type:Individual
Prefix:
First Name:RONDALE
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 THOMPSON ST
Mailing Address - Street 2:
Mailing Address - City:DUMONT
Mailing Address - State:NJ
Mailing Address - Zip Code:07628-3616
Mailing Address - Country:US
Mailing Address - Phone:845-262-8978
Mailing Address - Fax:
Practice Address - Street 1:7 THOMPSON ST
Practice Address - Street 2:
Practice Address - City:DUMONT
Practice Address - State:NJ
Practice Address - Zip Code:07628-3616
Practice Address - Country:US
Practice Address - Phone:845-262-8978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-09
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant