Provider Demographics
NPI:1073046652
Name:PETERSON, MELISSA C (DPT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:C
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:PO BOX 220
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-0220
Mailing Address - Country:US
Mailing Address - Phone:708-590-6663
Mailing Address - Fax:708-469-4100
Practice Address - Street 1:777 N YORK RD
Practice Address - Street 2:
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-3559
Practice Address - Country:US
Practice Address - Phone:630-819-8384
Practice Address - Fax:630-468-0605
Is Sole Proprietor?:No
Enumeration Date:2017-04-10
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070023205225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist