Provider Demographics
NPI:1780624387
Name:PETERSON, DANIEL P (PT, MS)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:P
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PT, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 KINGSLEY CT
Mailing Address - Street 2:
Mailing Address - City:FRANKENMUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48734-1270
Mailing Address - Country:US
Mailing Address - Phone:989-992-1671
Mailing Address - Fax:877-690-9097
Practice Address - Street 1:12729 E WASHINGTON RD STE 2
Practice Address - Street 2:
Practice Address - City:REESE
Practice Address - State:MI
Practice Address - Zip Code:48757-9722
Practice Address - Country:US
Practice Address - Phone:877-690-9096
Practice Address - Fax:877-690-9097
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2016-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501005682225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4362563Medicaid
MI0N75080Medicare PIN