Provider Demographics
NPI:1487853511
Name:PETERSON, LEAH MARCELLA (PT)
Entity Type:Individual
Prefix:MRS
First Name:LEAH
Middle Name:MARCELLA
Last Name:PETERSON
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 1:606 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:SD
Mailing Address - Zip Code:57013-1306
Mailing Address - Country:US
Mailing Address - Phone:605-764-3309
Mailing Address - Fax:
Practice Address - Street 1:440 N HIAWATHA DR
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:SD
Practice Address - Zip Code:57013-5800
Practice Address - Country:US
Practice Address - Phone:605-987-2621
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-18
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0433225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist