Provider Demographics
NPI:1407950546
Name:PETERSON, CAMILLE DIMONTE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:CAMILLE
Middle Name:DIMONTE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:DR
Other - First Name:CAMILLE
Other - Middle Name:DI MONTE
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:1476 US HIGHWAY 2
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL FALLS
Mailing Address - State:MI
Mailing Address - Zip Code:49920-9628
Mailing Address - Country:US
Mailing Address - Phone:906-875-3083
Mailing Address - Fax:
Practice Address - Street 1:2383 STATE HIGHWAY 17
Practice Address - Street 2:
Practice Address - City:PHELPS
Practice Address - State:WI
Practice Address - Zip Code:54554-9472
Practice Address - Country:US
Practice Address - Phone:715-545-3886
Practice Address - Fax:715-545-3412
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501004807225100000X
WI4377-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40203800OtherMEDICAID
MI4673910Medicaid
WI40203800OtherMEDICAID
MIOM87920Medicare ID - Type Unspecified