Provider Demographics
NPI:1669578266
Name:PETERSON, BRETT A (PT)
Entity type:Individual
Prefix:
First Name:BRETT
Middle Name:A
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10470 OLD PLACERVILLE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:800-470-0071
Mailing Address - Fax:
Practice Address - Street 1:568 N SUNRISE AVE
Practice Address - Street 2:#100
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3097
Practice Address - Country:US
Practice Address - Phone:916-865-1100
Practice Address - Fax:916-865-1105
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT23803225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT0238030Medicaid
0PT238032Medicare ID - Type Unspecified
CAAR869TMedicare PIN
CAPT0238030Medicaid