Provider Demographics
NPI:1225518376
Name:PETTERSON, LORI (OTR/L, CDMS)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:PETTERSON
Suffix:
Gender:F
Credentials:OTR/L, CDMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5488 S PARKCREST ST
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85298-3413
Mailing Address - Country:US
Mailing Address - Phone:612-280-7355
Mailing Address - Fax:
Practice Address - Street 1:1400 E SOUTHERN AVE STE 310
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-5695
Practice Address - Country:US
Practice Address - Phone:612-280-7355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-17
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ225X00000X
AZ007509225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist