Provider Demographics
NPI:1750425203
Name:PETERSON, MONIQUE (PT)
Entity type:Individual
Prefix:
First Name:MONIQUE
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18800 DELAWARE ST STE 350
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-6084
Mailing Address - Country:US
Mailing Address - Phone:714-848-8318
Mailing Address - Fax:714-848-8306
Practice Address - Street 1:18800 DELAWARE ST STE 350
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648-6084
Practice Address - Country:US
Practice Address - Phone:714-848-8318
Practice Address - Fax:714-848-8306
Is Sole Proprietor?:No
Enumeration Date:2007-02-17
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13318225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA556539Medicare Oscar/Certification