Provider Demographics
NPI:1376090118
Name:PETERSON, SAMUEL BRANDT (OT, MOT)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:BRANDT
Last Name:PETERSON
Suffix:
Gender:M
Credentials:OT, MOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 CORPORATE DR STE 400
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35242-5424
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:
Practice Address - Street 1:678 S COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:HARRISONVILLE
Practice Address - State:MO
Practice Address - Zip Code:64701-1653
Practice Address - Country:US
Practice Address - Phone:816-380-3325
Practice Address - Fax:816-380-3044
Is Sole Proprietor?:No
Enumeration Date:2016-09-09
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363945225X00000X
CA16730225X00000X
MO2021023073225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist