Provider Demographics
NPI:1649230780
Name:PETERSEN, SHELLE ANN (PT)
Entity Type:Individual
Prefix:MRS
First Name:SHELLE
Middle Name:ANN
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 N 22ND ST
Mailing Address - Street 2:THERAPY SERVICES
Mailing Address - City:BLAIR
Mailing Address - State:NE
Mailing Address - Zip Code:68008-1128
Mailing Address - Country:US
Mailing Address - Phone:402-426-1129
Mailing Address - Fax:
Practice Address - Street 1:810 N 22ND ST
Practice Address - Street 2:
Practice Address - City:BLAIR
Practice Address - State:NE
Practice Address - Zip Code:68008-1128
Practice Address - Country:US
Practice Address - Phone:402-426-1129
Practice Address - Fax:402-426-8511
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1515225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist