Provider Demographics
NPI:1396513347
Name:PETTERSEN, THERESE
Entity type:Individual
Prefix:
First Name:THERESE
Middle Name:
Last Name:PETTERSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 E CAMPBELL AVE APT 4016
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-4279
Mailing Address - Country:US
Mailing Address - Phone:602-989-8096
Mailing Address - Fax:
Practice Address - Street 1:775 E WILLETTA ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2723
Practice Address - Country:US
Practice Address - Phone:480-581-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-19
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ009304225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist