Provider Demographics
NPI:1639782618
Name:PETERSON, NATHALIE (OTR/L)
Entity Type:Individual
Prefix:
First Name:NATHALIE
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 FAIRFAX AVE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49001-4259
Mailing Address - Country:US
Mailing Address - Phone:415-515-3929
Mailing Address - Fax:
Practice Address - Street 1:117 W PATERSON ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-2557
Practice Address - Country:US
Practice Address - Phone:269-349-2641
Practice Address - Fax:269-466-5522
Is Sole Proprietor?:No
Enumeration Date:2020-08-28
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201010982225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist