Provider Demographics
NPI:1235508581
Name:PETERSEN, SUSAN (MPT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2012 PHALAROPE CT
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-4734
Mailing Address - Country:US
Mailing Address - Phone:714-580-2868
Mailing Address - Fax:714-241-1007
Practice Address - Street 1:2012 PHALAROPE CT
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-4734
Practice Address - Country:US
Practice Address - Phone:714-580-2868
Practice Address - Fax:714-241-1007
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-16
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18793225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist