Provider Demographics
NPI:1972088565
Name:PETERSON, HALEY TANYA (DPT)
Entity type:Individual
Prefix:
First Name:HALEY
Middle Name:TANYA
Last Name:PETERSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11995 SINGLETREE LN STE 120
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-5338
Mailing Address - Country:US
Mailing Address - Phone:952-373-5720
Mailing Address - Fax:763-260-7653
Practice Address - Street 1:11995 SINGLETREE LN STE 120
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344
Practice Address - Country:US
Practice Address - Phone:952-373-5141
Practice Address - Fax:763-260-7653
Is Sole Proprietor?:No
Enumeration Date:2018-09-28
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60885893225100000X
MN11173225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist