Provider Demographics
NPI:1689296865
Name:PETERSON, BETHANY (PT, DPT)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9616 LOWELL AVE
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66212-3304
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:701 E 63RD ST STE G10
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64110-3305
Practice Address - Country:US
Practice Address - Phone:913-575-8529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-11
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-05180225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist