Provider Demographics
NPI:1558434928
Name:PETERSON, THEODORE WILLIAM (OTR)
Entity Type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:WILLIAM
Last Name:PETERSON
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2080 ARDELLA DR
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-2615
Mailing Address - Country:US
Mailing Address - Phone:208-904-1574
Mailing Address - Fax:
Practice Address - Street 1:IDAHO STATE UNIVERSITY
Practice Address - Street 2:CAMPUS BOX 8045
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83209-0001
Practice Address - Country:US
Practice Address - Phone:208-282-4631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00800225X00000X
IDOT-886225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist