Provider Demographics
NPI:1356451561
Name:PETERSON, JULIE ANNE (PT)
Entity Type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:ANNE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5112 NICHOLAS ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68132-1434
Mailing Address - Country:US
Mailing Address - Phone:402-498-4397
Mailing Address - Fax:
Practice Address - Street 1:7205 W CENTER RD
Practice Address - Street 2:101
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68124-2380
Practice Address - Country:US
Practice Address - Phone:402-390-1027
Practice Address - Fax:402-390-1037
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2020225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE100251951-00Medicaid
NE100251951-00Medicaid