Provider Demographics
NPI:1245534411
Name:PETERSON, MARIA MONIQUE (PTA)
Entity type:Individual
Prefix:MRS
First Name:MARIA
Middle Name:MONIQUE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N1499 FOREST DR
Mailing Address - Street 2:
Mailing Address - City:NORWAY
Mailing Address - State:MI
Mailing Address - Zip Code:49870-2008
Mailing Address - Country:US
Mailing Address - Phone:906-563-1453
Mailing Address - Fax:
Practice Address - Street 1:N1499 FOREST DR
Practice Address - Street 2:
Practice Address - City:NORWAY
Practice Address - State:MI
Practice Address - Zip Code:49870-2008
Practice Address - Country:US
Practice Address - Phone:906-563-1453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-03
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1541-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant