Provider Demographics
NPI:1538834460
Name:PETERSON, EMILY MARIE (PTA)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:MARIE
Last Name:PETERSON
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 1:29842 LONGHORN DR
Mailing Address - Street 2:
Mailing Address - City:CANYON LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:92587-7642
Mailing Address - Country:US
Mailing Address - Phone:714-603-2037
Mailing Address - Fax:
Practice Address - Street 1:28975 OLD TOWN FRONT ST STE 201
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-2863
Practice Address - Country:US
Practice Address - Phone:951-595-1738
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-12
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPTA48577225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant