Provider Demographics
NPI:1538114764
Name:PETERSON, SUE MARIE (MA LAT)
Entity Type:Individual
Prefix:MRS
First Name:SUE
Middle Name:MARIE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MA LAT
Other - Prefix:MS
Other - First Name:SUSAN
Other - Middle Name:MARIE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 461
Mailing Address - Street 2:
Mailing Address - City:NEVADA
Mailing Address - State:IA
Mailing Address - Zip Code:50201-0461
Mailing Address - Country:US
Mailing Address - Phone:515-382-3366
Mailing Address - Fax:515-382-1576
Practice Address - Street 1:1507 N 1ST ST
Practice Address - Street 2:
Practice Address - City:INDIANOLA
Practice Address - State:IA
Practice Address - Zip Code:50125
Practice Address - Country:US
Practice Address - Phone:515-961-7435
Practice Address - Fax:515-961-7436
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA123BB99612255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer