Provider Demographics
NPI:1225344690
Name:PETERSON, JANIS L (PTA)
Entity Type:Individual
Prefix:
First Name:JANIS
Middle Name:L
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 MARKET PLACE DR # 3B
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:ME
Mailing Address - Zip Code:03909-1680
Mailing Address - Country:US
Mailing Address - Phone:207-351-3078
Mailing Address - Fax:207-351-3083
Practice Address - Street 1:10 MARKET PLACE DR # 3B
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:ME
Practice Address - Zip Code:03909-1680
Practice Address - Country:US
Practice Address - Phone:207-351-3078
Practice Address - Fax:207-351-3083
Is Sole Proprietor?:No
Enumeration Date:2010-08-24
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA3642225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant