Provider Demographics
NPI:1326445198
Name:PETERSEN, MATHEW JAMES (ATC)
Entity Type:Individual
Prefix:
First Name:MATHEW
Middle Name:JAMES
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10214 MUSICK RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63123-5066
Mailing Address - Country:US
Mailing Address - Phone:314-882-7043
Mailing Address - Fax:
Practice Address - Street 1:10214 MUSICK RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63123-5066
Practice Address - Country:US
Practice Address - Phone:314-882-7043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-21
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20120226072255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer