Provider Demographics
NPI:1518006444
Name:PETERSON, BREK LAMONT (PT)
Entity Type:Individual
Prefix:MR
First Name:BREK
Middle Name:LAMONT
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 W IRON SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-1414
Mailing Address - Country:US
Mailing Address - Phone:928-771-2977
Mailing Address - Fax:928-771-2987
Practice Address - Street 1:1320 W IRON SPRINGS RD
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-1414
Practice Address - Country:US
Practice Address - Phone:928-771-2977
Practice Address - Fax:928-771-2987
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5079225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1669480968OtherNPI
AZP00468Medicare UPIN
AZ64027Medicare PIN
AZ64026Medicare PIN