Provider Demographics
NPI:1619169901
Name:PETERSON, MICHELLE (DEVELOPMENTAL THERAP)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:DEVELOPMENTAL THERAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:579 RIFORD RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-4236
Mailing Address - Country:US
Mailing Address - Phone:630-858-2336
Mailing Address - Fax:630-942-0377
Practice Address - Street 1:579 RIFORD RD
Practice Address - Street 2:
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-4236
Practice Address - Country:US
Practice Address - Phone:630-858-2336
Practice Address - Fax:630-942-0377
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-10
Last Update Date:2007-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist