Provider Demographics
NPI:1922412394
Name:PETERSON, JAMES W
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:W
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 1:381 MAIN ST
Mailing Address - Street 2:APT 3
Mailing Address - City:OWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13827-1644
Mailing Address - Country:US
Mailing Address - Phone:607-972-8519
Mailing Address - Fax:
Practice Address - Street 1:332 BROAD ST
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:NY
Practice Address - Zip Code:14892-1345
Practice Address - Country:US
Practice Address - Phone:607-948-4047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-13
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018910-1225X00000X
PAOC012981225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist