Provider Demographics
NPI:1871261156
Name:PETERSON, EVAN T (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:EVAN
Middle Name:T
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W COLD SPRING LN STE 300
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21210-2831
Mailing Address - Country:US
Mailing Address - Phone:410-662-7977
Mailing Address - Fax:410-662-4544
Practice Address - Street 1:200 W COLD SPRING LN STE 300
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21210-2831
Practice Address - Country:US
Practice Address - Phone:410-662-7977
Practice Address - Fax:410-662-4544
Is Sole Proprietor?:No
Enumeration Date:2021-09-01
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD28606225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist