Provider Demographics
NPI:1124229281
Name:PETERSON, KATHY J (PHYSICAL THERAPY ASS)
Entity Type:Individual
Prefix:MRS
First Name:KATHY
Middle Name:J
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PHYSICAL THERAPY ASS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1314 JOHNSON ST
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-5616
Mailing Address - Country:US
Mailing Address - Phone:608-784-4471
Mailing Address - Fax:
Practice Address - Street 1:2400 DIAGONAL RD
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-7619
Practice Address - Country:US
Practice Address - Phone:608-784-4471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI52-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant