Provider Demographics
NPI:1770822413
Name:PETERS, KATHLEEN NORA (COTA)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:NORA
Last Name:PETERS
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 E BECKERT ROAD
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:WI
Mailing Address - Zip Code:54940
Mailing Address - Country:US
Mailing Address - Phone:920-982-5354
Mailing Address - Fax:920-982-9149
Practice Address - Street 1:107 E BECKERT RD
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:WI
Practice Address - Zip Code:54961-2509
Practice Address - Country:US
Practice Address - Phone:920-982-5354
Practice Address - Fax:920-982-9149
Is Sole Proprietor?:No
Enumeration Date:2013-01-31
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1154-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1154-27OtherSTATE LICENSE