Provider Demographics
NPI:1770020273
Name:PETERSEN, MEGAN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:PETERSEN
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 1:1128 W 26TH ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77008-1750
Mailing Address - Country:US
Mailing Address - Phone:713-464-8357
Mailing Address - Fax:
Practice Address - Street 1:711 W 38TH ST STE C11
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1137
Practice Address - Country:US
Practice Address - Phone:512-302-3922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-23
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1277268225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist