Provider Demographics
NPI:1578629341
Name:PETERSON, MARK L (OTR)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:L
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 1:40520 CO HWY 34
Mailing Address - Street 2:
Mailing Address - City:OGEMA
Mailing Address - State:MN
Mailing Address - Zip Code:56569
Mailing Address - Country:US
Mailing Address - Phone:218-983-6385
Mailing Address - Fax:218-983-3773
Practice Address - Street 1:40520 CO HWY 34
Practice Address - Street 2:
Practice Address - City:OGEMA
Practice Address - State:MN
Practice Address - Zip Code:56569
Practice Address - Country:US
Practice Address - Phone:218-983-6385
Practice Address - Fax:218-983-3773
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103166225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist