Provider Demographics
NPI:1104365733
Name:PETERSEN, SHAREE
Entity Type:Individual
Prefix:
First Name:SHAREE
Middle Name:
Last Name:PETERSEN
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 1:1651 N 86TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68505-3719
Mailing Address - Country:US
Mailing Address - Phone:402-484-7117
Mailing Address - Fax:
Practice Address - Street 1:6900 A ST STE 102
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68510-4120
Practice Address - Country:US
Practice Address - Phone:402-436-2535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-15
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.0014485261QP2000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy