Provider Demographics
NPI:1275252272
Name:PETERSON, CASEY J (ATP)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:J
Last Name:PETERSON
Suffix:
Gender:M
Credentials:ATP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 218418
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77218-8418
Mailing Address - Country:US
Mailing Address - Phone:281-492-2799
Mailing Address - Fax:281-492-7479
Practice Address - Street 1:16820 BARKER SPRINGS RD STE E500
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77084-5040
Practice Address - Country:US
Practice Address - Phone:281-492-2799
Practice Address - Fax:281-492-7479
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-23
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ATP85047247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXATP85047OtherASSISTIVE TECHNOLOGY PROFESSIONAL