Provider Demographics
NPI:1932325172
Name:PETERSON, CHRISTINE JO (MPT)
Entity Type:Individual
Prefix:MRS
First Name:CHRISTINE
Middle Name:JO
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 1:2114 HAMMOND AVE
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-5038
Mailing Address - Country:US
Mailing Address - Phone:715-394-9384
Mailing Address - Fax:
Practice Address - Street 1:1800 NEW YORK AVE
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-2008
Practice Address - Country:US
Practice Address - Phone:715-394-5591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4841-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist