Provider Demographics
NPI:1497770663
Name:PETERSON, BARBARA A (PT)
Entity Type:Individual
Prefix:MRS
First Name:BARBARA
Middle Name:A
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 1:1225 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:IL
Mailing Address - Zip Code:61356-9507
Mailing Address - Country:US
Mailing Address - Phone:815-875-2348
Mailing Address - Fax:815-875-2334
Practice Address - Street 1:1225 N 6TH ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:IL
Practice Address - Zip Code:61356-9507
Practice Address - Country:US
Practice Address - Phone:815-875-2348
Practice Address - Fax:815-875-2334
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070005259225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$002 ILMedicaid
IL$$$$$$$$$002 ILMedicaid
ILK14155Medicare ID - Type Unspecified