Provider Demographics
NPI:1114004231
Name:PEDERSEN, TIMOTHY S (MS, PT)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:S
Last Name:PEDERSEN
Suffix:
Gender:M
Credentials:MS, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 SARAHS WAY
Mailing Address - Street 2:
Mailing Address - City:FAIRHAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02719-3161
Mailing Address - Country:US
Mailing Address - Phone:508-991-2918
Mailing Address - Fax:508-994-3068
Practice Address - Street 1:17 SARAHS WAY
Practice Address - Street 2:
Practice Address - City:FAIRHAVEN
Practice Address - State:MA
Practice Address - Zip Code:02719-3161
Practice Address - Country:US
Practice Address - Phone:508-991-2918
Practice Address - Fax:508-994-3068
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8305225100000X
RIPT01872225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110088219AMedicaid