Provider Demographics
NPI:1013038900
Name:PETERSON, LINA MARIA (PT)
Entity Type:Individual
Prefix:MRS
First Name:LINA
Middle Name:MARIA
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 1:125 NW 109TH AVE APT 105
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33026-5116
Mailing Address - Country:US
Mailing Address - Phone:954-673-2623
Mailing Address - Fax:954-447-3131
Practice Address - Street 1:10794 PINES BLVD
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33026-3920
Practice Address - Country:US
Practice Address - Phone:954-447-0296
Practice Address - Fax:954-447-3131
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23246225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist