Provider Demographics
NPI:1811543895
Name:PETERSON, KEVIN NICHOLAS (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:NICHOLAS
Last Name:PETERSON
Suffix:
Gender:M
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 1:2412 E ATHENS AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92867-4408
Mailing Address - Country:US
Mailing Address - Phone:661-713-4584
Mailing Address - Fax:
Practice Address - Street 1:980 ROOSEVELT STE 100
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92620-3670
Practice Address - Country:US
Practice Address - Phone:949-333-6400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-14
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2971672251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics