Provider Demographics
NPI:1821514860
Name:PETERSON, STEPHANIE LEIGH (DPT, OTR, ATC)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:LEIGH
Last Name:PETERSON
Suffix:
Gender:F
Credentials:DPT, OTR, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1029 POWDERHORN RD
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-3379
Mailing Address - Country:US
Mailing Address - Phone:843-670-7643
Mailing Address - Fax:
Practice Address - Street 1:1029 POWDERHORN RD
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29681-3379
Practice Address - Country:US
Practice Address - Phone:843-670-7643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-22
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL36892255A2300X
FL17596225X00000X
SC5988225X00000X
SC9750225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC5988OtherOCCUPATIONAL THERAPY LICENSE