Provider Demographics
NPI:1447557616
Name:PETERSON, GARY G (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:G
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4461 WOODBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-2387
Mailing Address - Country:US
Mailing Address - Phone:850-729-2709
Mailing Address - Fax:
Practice Address - Street 1:4461 WOODBRIDGE RD
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-2387
Practice Address - Country:US
Practice Address - Phone:850-729-2709
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-23
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT2579225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist