Provider Demographics
NPI:1124363452
Name:PETERSEN, LYNN (OTA/L)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:OTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5211 SANDRA DR
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43613-2535
Mailing Address - Country:US
Mailing Address - Phone:419-474-4206
Mailing Address - Fax:
Practice Address - Street 1:5757 WHITEFORD RD
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-1632
Practice Address - Country:US
Practice Address - Phone:419-882-1875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-27
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOTA1021224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant