Provider Demographics
NPI:1114454923
Name:PETERSEN, MCKAYLA (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:MCKAYLA
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:ND
Mailing Address - Zip Code:58237-1379
Mailing Address - Country:US
Mailing Address - Phone:701-352-4552
Mailing Address - Fax:701-365-8134
Practice Address - Street 1:701 W 6TH ST
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:ND
Practice Address - Zip Code:58237-1379
Practice Address - Country:US
Practice Address - Phone:701-871-8765
Practice Address - Fax:701-352-4410
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND2110225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1472555Medicaid