Provider Demographics
NPI:1659493732
Name:PETERS, MONIQUE
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:
Last Name:PETERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1056 PARK RD
Mailing Address - Street 2:
Mailing Address - City:LEESPORT
Mailing Address - State:PA
Mailing Address - Zip Code:19533-9016
Mailing Address - Country:US
Mailing Address - Phone:610-926-6828
Mailing Address - Fax:610-562-4938
Practice Address - Street 1:125 HOLLY RD
Practice Address - Street 2:
Practice Address - City:HAMBURG
Practice Address - State:PA
Practice Address - Zip Code:19526-8729
Practice Address - Country:US
Practice Address - Phone:610-562-2284
Practice Address - Fax:610-562-4938
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT000489E225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist