Provider Demographics
NPI:1851323067
Name:PETERSON, CONSTANCE V (PT)
Entity Type:Individual
Prefix:MRS
First Name:CONSTANCE
Middle Name:V
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:211 CENTER PARK DRIVE
Mailing Address - Street 2:SUITE 3060
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37922
Mailing Address - Country:US
Mailing Address - Phone:865-966-8545
Mailing Address - Fax:865-966-3936
Practice Address - Street 1:187 GALLAHER RD
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:TN
Practice Address - Zip Code:37763-4721
Practice Address - Country:US
Practice Address - Phone:865-376-4620
Practice Address - Fax:865-376-1759
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10952251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN5440745Medicaid
TN4005129OtherBLUECROSS BLUESHIELD