Provider Demographics
NPI:1972778405
Name:PETERSON, DIANE K (PT)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:K
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NE
Mailing Address - Zip Code:68787-1941
Mailing Address - Country:US
Mailing Address - Phone:402-833-5343
Mailing Address - Fax:402-833-5349
Practice Address - Street 1:208 MAIN ST
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NE
Practice Address - Zip Code:68787-1941
Practice Address - Country:US
Practice Address - Phone:402-833-5343
Practice Address - Fax:402-833-5349
Is Sole Proprietor?:No
Enumeration Date:2008-04-25
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE687225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025617600Medicaid