Provider Demographics
NPI:1891093175
Name:PETERSON, LAURA (PT)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11538
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76547-1538
Mailing Address - Country:US
Mailing Address - Phone:254-245-9177
Mailing Address - Fax:254-245-9178
Practice Address - Street 1:101B W CENTRAL TEXAS EXPY STE D
Practice Address - Street 2:
Practice Address - City:HARKER HEIGHTS
Practice Address - State:TX
Practice Address - Zip Code:76548-1704
Practice Address - Country:US
Practice Address - Phone:254-630-1186
Practice Address - Fax:254-213-9235
Is Sole Proprietor?:No
Enumeration Date:2011-03-10
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1202126225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist