Provider Demographics
NPI:1790828531
Name:PETERSON, TODD (ATC, PTA)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:ATC, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 195
Mailing Address - Street 2:
Mailing Address - City:EAST PEMBROKE
Mailing Address - State:NY
Mailing Address - Zip Code:14056
Mailing Address - Country:US
Mailing Address - Phone:585-762-8883
Mailing Address - Fax:
Practice Address - Street 1:120 ERIE CANAL DR
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-4607
Practice Address - Country:US
Practice Address - Phone:585-225-6296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003649-1225200000X
NY001176-12255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Not Answered2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer