Provider Demographics
NPI:1760771109
Name:PETERSEN, GARY MARK (OTD, OTR/L)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:MARK
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:249 E OCEAN BLVD STE 440
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-4806
Mailing Address - Country:US
Mailing Address - Phone:888-808-7838
Mailing Address - Fax:866-620-3943
Practice Address - Street 1:249 E OCEAN BLVD STE 440
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90802-4806
Practice Address - Country:US
Practice Address - Phone:888-808-7838
Practice Address - Fax:866-620-3943
Is Sole Proprietor?:No
Enumeration Date:2011-04-06
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10906225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist