Provider Demographics
NPI:1508002403
Name:PETERSEN, MOLLY JO (PTA)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:JO
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2420 NW 115TH AVE
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33065-3422
Mailing Address - Country:US
Mailing Address - Phone:954-552-4351
Mailing Address - Fax:
Practice Address - Street 1:2420 NW 115TH AVE
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33065-3422
Practice Address - Country:US
Practice Address - Phone:954-552-4351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-23
Last Update Date:2008-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA1659225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant