Provider Demographics
NPI:1467508176
Name:PETERSEN, TERESA (PT, MS, PCS)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:PT, MS, PCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6600 COLLEGE BLVD
Mailing Address - Street 2:SUITE 307
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66211-1939
Mailing Address - Country:US
Mailing Address - Phone:913-345-1997
Mailing Address - Fax:913-345-1990
Practice Address - Street 1:6600 COLLEGE BLVD
Practice Address - Street 2:SUITE 307
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66211-1939
Practice Address - Country:US
Practice Address - Phone:913-345-1997
Practice Address - Fax:913-345-1990
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-004902251P0200X
MO20040341622251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO485072409Medicaid
KS100359840BMedicaid