Provider Demographics
NPI:1659172096
Name:PETERSEN, CHALISE
Entity type:Individual
Prefix:
First Name:CHALISE
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5500 MING AVE STE 410
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93309-4631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:65 N 1150 W
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:UT
Practice Address - Zip Code:84737-2062
Practice Address - Country:US
Practice Address - Phone:435-879-7677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-21
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT14208038-4003225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT14208038-4003OtherLICENSE