Provider Demographics
NPI:1225212806
Name:PETERSON, CHRISTOPHER DAVID (MPT, MBA)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:DAVID
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MPT, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 102
Mailing Address - Street 2:
Mailing Address - City:LA PLATA
Mailing Address - State:MD
Mailing Address - Zip Code:20646-0102
Mailing Address - Country:US
Mailing Address - Phone:301-539-3807
Mailing Address - Fax:301-539-3814
Practice Address - Street 1:144 DRURY DR
Practice Address - Street 2:
Practice Address - City:LA PLATA
Practice Address - State:MD
Practice Address - Zip Code:20646-2064
Practice Address - Country:US
Practice Address - Phone:301-539-3807
Practice Address - Fax:301-539-3814
Is Sole Proprietor?:No
Enumeration Date:2007-12-19
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD19057225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist