Provider Demographics
NPI:1033184064
Name:PETERS, CAROLYN RAE (MA, ATC, CSCS)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:RAE
Last Name:PETERS
Suffix:
Gender:F
Credentials:MA, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5742 HUGHES ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92115-6513
Mailing Address - Country:US
Mailing Address - Phone:619-594-7660
Mailing Address - Fax:619-594-7654
Practice Address - Street 1:5505 CAMPANILE DR.
Practice Address - Street 2:AAC 1402
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92182-4313
Practice Address - Country:US
Practice Address - Phone:619-594-7660
Practice Address - Fax:619-594-7654
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer