Provider Demographics
NPI:1700166295
Name:PETERSEN, BENNET (MS, OTR/L)
Entity type:Individual
Prefix:
First Name:BENNET
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3921 30TH AVE STE C
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-1957
Mailing Address - Country:US
Mailing Address - Phone:262-925-5004
Mailing Address - Fax:262-925-5001
Practice Address - Street 1:10222 74TH ST STE 211
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-6810
Practice Address - Country:US
Practice Address - Phone:262-925-5020
Practice Address - Fax:262-925-5021
Is Sole Proprietor?:No
Enumeration Date:2011-08-28
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6674-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty