Provider Demographics
NPI:1376621169
Name:PETERSON, RACHEL (LPT)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3833 COON RAPIDS BLVD NW STE 100
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-2697
Mailing Address - Country:US
Mailing Address - Phone:763-427-8320
Mailing Address - Fax:763-712-5429
Practice Address - Street 1:3833 COON RAPIDS BLVD NW STE 100
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-2697
Practice Address - Country:US
Practice Address - Phone:763-427-8320
Practice Address - Fax:763-712-5429
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
MN7483225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1376621169Medicaid