Provider Demographics
NPI:1740689561
Name:PETERSON, CORY (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:CORY
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13915 BURNET RD STE 103
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78728-6518
Mailing Address - Country:US
Mailing Address - Phone:210-269-5287
Mailing Address - Fax:512-355-1966
Practice Address - Street 1:13915 BURNET RD STE 103
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78728-6518
Practice Address - Country:US
Practice Address - Phone:512-710-6516
Practice Address - Fax:512-354-4068
Is Sole Proprietor?:No
Enumeration Date:2014-08-18
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1248191225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist