Provider Demographics
NPI:1083355804
Name:PETERSON, COURTNEY JEAN
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:JEAN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19832 ALANA RD
Mailing Address - Street 2:
Mailing Address - City:CASTRO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94546-4505
Mailing Address - Country:US
Mailing Address - Phone:510-421-1335
Mailing Address - Fax:
Practice Address - Street 1:210 PORTER DR
Practice Address - Street 2:
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-1588
Practice Address - Country:US
Practice Address - Phone:925-743-3322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics