Provider Demographics
NPI:1821505918
Name:PEDERSEN, ANTHONY I (OTR/L)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:PEDERSEN
Suffix:I
Gender:M
Credentials: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:PO BOX 393
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:NH
Mailing Address - Zip Code:03851-0393
Mailing Address - Country:US
Mailing Address - Phone:801-367-8863
Mailing Address - Fax:
Practice Address - Street 1:595 WHITE MOUNTAIN HIGHWAY
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:NH
Practice Address - Zip Code:03851
Practice Address - Country:US
Practice Address - Phone:801-367-8863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-10
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9873545-4201225X00000X
NH2707225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty