Provider Demographics
NPI:1891390399
Name:PETERSEN, JOANNA BROOKE (OTR/L)
Entity Type:Individual
Prefix:
First Name:JOANNA
Middle Name:BROOKE
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 342
Mailing Address - Street 2:
Mailing Address - City:QUITMAN
Mailing Address - State:LA
Mailing Address - Zip Code:71268-0342
Mailing Address - Country:US
Mailing Address - Phone:318-254-3052
Mailing Address - Fax:
Practice Address - Street 1:4680 OLD BROWNLEE RD
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111
Practice Address - Country:US
Practice Address - Phone:318-326-4259
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA324602225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist