Provider Demographics
NPI:1013013176
Name:PETERSEN, GREG EDWARD (PT)
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:EDWARD
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3878 W CARSON ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-6707
Mailing Address - Country:US
Mailing Address - Phone:310-543-4655
Mailing Address - Fax:310-543-1743
Practice Address - Street 1:3878 W CARSON ST
Practice Address - Street 2:SUITE 100
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-6707
Practice Address - Country:US
Practice Address - Phone:310-543-4655
Practice Address - Fax:310-543-1743
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 20757225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist