Provider Demographics
NPI:1851418248
Name:PETERSON, COLLEEN (MPT)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1218 MELODY LN
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:PA
Mailing Address - Zip Code:18966-4320
Mailing Address - Country:US
Mailing Address - Phone:215-364-5102
Mailing Address - Fax:
Practice Address - Street 1:8015 LAWNDALE AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19111-1507
Practice Address - Country:US
Practice Address - Phone:215-725-2525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT003064E225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist