Provider Demographics
NPI:1235680893
Name:PETERSON, MARY KATHRYN (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:KATHRYN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 S BLOOMINGDALE RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60108
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:165 S BLOOMINGDALE RD
Practice Address - Street 2:
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108-1434
Practice Address - Country:US
Practice Address - Phone:630-980-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-19
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.011480225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist