Provider Demographics
NPI:1689087223
Name:PETERSEN, ILIANA
Entity Type:Individual
Prefix:
First Name:ILIANA
Middle Name:
Last Name:PETERSEN
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 1:335 ROLLING HILLS AVE
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94403-4320
Mailing Address - Country:US
Mailing Address - Phone:650-291-1527
Mailing Address - Fax:
Practice Address - Street 1:1275 CRANE ST
Practice Address - Street 2:
Practice Address - City:MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94025-4212
Practice Address - Country:US
Practice Address - Phone:650-322-6501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-10
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4185225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist