Provider Demographics
NPI:1356891394
Name:PETERSEN, MARI (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:MARI
Middle Name:
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 1:112 SAINT OLAF AVE S
Mailing Address - Street 2:
Mailing Address - City:CANBY
Mailing Address - State:MN
Mailing Address - Zip Code:56220-1433
Mailing Address - Country:US
Mailing Address - Phone:507-223-7277
Mailing Address - Fax:
Practice Address - Street 1:112 SAINT OLAF AVE S
Practice Address - Street 2:
Practice Address - City:CANBY
Practice Address - State:MN
Practice Address - Zip Code:56220-1433
Practice Address - Country:US
Practice Address - Phone:507-223-7277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-13
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0618225X00000X
MN103028225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist