Provider Demographics
NPI:1811953342
Name:PETERSON, CONNIE LEE (ATC, PHD)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:LEE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:ATC, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3839 MILL RACE CT
Mailing Address - Street 2:
Mailing Address - City:HARRISONBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22801-2270
Mailing Address - Country:US
Mailing Address - Phone:540-568-7085
Mailing Address - Fax:540-568-3336
Practice Address - Street 1:JAMES MADISON UNIVERSITY
Practice Address - Street 2:MSC 4301
Practice Address - City:HARRISONBURG
Practice Address - State:VA
Practice Address - Zip Code:22807-0001
Practice Address - Country:US
Practice Address - Phone:540-568-7085
Practice Address - Fax:540-568-3336
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260006222255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer