Provider Demographics
NPI:1235721762
Name:PETERSON, SHELBY (PT, DPT)
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4055 OCEANSIDE BLVD STE F
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92056-5821
Mailing Address - Country:US
Mailing Address - Phone:760-842-7519
Mailing Address - Fax:760-657-2994
Practice Address - Street 1:4055 OCEANSIDE BLVD STE F
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92056-5821
Practice Address - Country:US
Practice Address - Phone:760-842-7519
Practice Address - Fax:760-657-2994
Is Sole Proprietor?:No
Enumeration Date:2021-02-05
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA299423225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist