Provider Demographics
NPI:1588780787
Name:PETERSON, LYNETTE (COTA)
Entity type:Individual
Prefix:
First Name:LYNETTE
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16413 HAROLD ST
Mailing Address - Street 2:
Mailing Address - City:OAK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60452-4203
Mailing Address - Country:US
Mailing Address - Phone:708-280-3302
Mailing Address - Fax:
Practice Address - Street 1:421 DORIS AVE
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60433-2569
Practice Address - Country:US
Practice Address - Phone:815-727-8776
Practice Address - Fax:815-774-9152
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant