Provider Demographics
NPI:1043888977
Name:PHETERSON, RAIZEL (OTR/L)
Entity Type:Individual
Prefix:
First Name:RAIZEL
Middle Name:
Last Name:PHETERSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2318 BRIGHT LEAF WAY
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-3470
Mailing Address - Country:US
Mailing Address - Phone:443-760-7891
Mailing Address - Fax:
Practice Address - Street 1:11 KELLER RD
Practice Address - Street 2:
Practice Address - City:PIKESVILLE
Practice Address - State:MD
Practice Address - Zip Code:21208-1308
Practice Address - Country:US
Practice Address - Phone:410-415-5260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-16
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD09248225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD09248OtherSTATE OF MARYLAND DEPARTMENT OF HEALTH AND MENTAL HYGIENE