Provider Demographics
NPI:1083025571
Name:PETERSEN, DENIECE P (DPT)
Entity Type:Individual
Prefix:
First Name:DENIECE
Middle Name:P
Last Name:PETERSEN
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 1:325 S 1ST AVE
Mailing Address - Street 2:P.O. BOX 435
Mailing Address - City:BROKEN BOW
Mailing Address - State:NE
Mailing Address - Zip Code:68822-0435
Mailing Address - Country:US
Mailing Address - Phone:308-872-5111
Mailing Address - Fax:308-872-5115
Practice Address - Street 1:325 S 1ST AVE
Practice Address - Street 2:
Practice Address - City:BROKEN BOW
Practice Address - State:NE
Practice Address - Zip Code:68822-0435
Practice Address - Country:US
Practice Address - Phone:308-872-5111
Practice Address - Fax:308-872-5115
Is Sole Proprietor?:No
Enumeration Date:2014-05-19
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2999225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE12685767OtherCAQH
NE12685767OtherCAQH