Provider Demographics
NPI:1851825319
Name:PETERSON, COLLIN
Entity Type:Individual
Prefix:
First Name:COLLIN
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9803 CRAIG MITCHELL LN
Mailing Address - Street 2:
Mailing Address - City:SHADOW HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91040-1634
Mailing Address - Country:US
Mailing Address - Phone:818-438-9218
Mailing Address - Fax:
Practice Address - Street 1:3720 LACLEDE AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-3300
Practice Address - Country:US
Practice Address - Phone:818-438-9218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-11
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer