Provider Demographics
NPI:1467471102
Name:PETERSEN, CHERYL M (PT)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:M
Last Name:PETERSEN
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 1:1085 NIAGARA LN
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53074-1766
Mailing Address - Country:US
Mailing Address - Phone:262-268-7260
Mailing Address - Fax:
Practice Address - Street 1:1085 NIAGARA LN
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:WI
Practice Address - Zip Code:53074-1766
Practice Address - Country:US
Practice Address - Phone:262-268-7260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9865-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist