Provider Demographics
NPI:1114205226
Name:PETERSEN, LEAH (RPT)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11901 ROSEWOOD ST
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66209-3533
Mailing Address - Country:US
Mailing Address - Phone:913-498-2742
Mailing Address - Fax:
Practice Address - Street 1:10000 W 75TH ST
Practice Address - Street 2:STE 121
Practice Address - City:SHAWNEE MISSION
Practice Address - State:KS
Practice Address - Zip Code:66204-2209
Practice Address - Country:US
Practice Address - Phone:913-362-7518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-25
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010042345225100000X
KS11-04131225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist