Provider Demographics
NPI:1558400283
Name:PETERSON, DENISE MARIE
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:MARIE
Last Name:PETERSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 BREWSTER BLVD
Mailing Address - Street 2:
Mailing Address - City:CAMP LEJEUNE
Mailing Address - State:NC
Mailing Address - Zip Code:28547-2575
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 BREWSTER BLVD
Practice Address - Street 2:
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28547-2575
Practice Address - Country:US
Practice Address - Phone:252-633-8640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10786225100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC018TEOtherBLUE CROSS GROUP BILLING NUMBER