Provider Demographics
NPI:1144207044
Name:PETERSON, BEN (MSPT)
Entity Type:Individual
Prefix:MR
First Name:BEN
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5541 W 98TH PL
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66207-2961
Mailing Address - Country:US
Mailing Address - Phone:913-940-4728
Mailing Address - Fax:816-373-2842
Practice Address - Street 1:4460 S NOLAND RD
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64055-4743
Practice Address - Country:US
Practice Address - Phone:816-373-2845
Practice Address - Fax:816-373-2842
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004020798225100000X
KS11-03430225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist