Provider Demographics
NPI:1225596950
Name:PETERSON, LAURA MICHELLE
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:MICHELLE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:HALPIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:607 LITCHFIELD ROAD
Mailing Address - Street 2:
Mailing Address - City:GILLESPIE
Mailing Address - State:IL
Mailing Address - Zip Code:62033
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:607 LITCHFIELD ROAD
Practice Address - Street 2:
Practice Address - City:GILLESPIE
Practice Address - State:IL
Practice Address - Zip Code:62033
Practice Address - Country:US
Practice Address - Phone:217-280-4405
Practice Address - Fax:217-280-4406
Is Sole Proprietor?:No
Enumeration Date:2019-03-12
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist