Provider Demographics
NPI:1821399338
Name:PETERSON, KATIE J (PT)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:J
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 1:1443 ASHBURY LN W
Mailing Address - Street 2:
Mailing Address - City:ROSELLE
Mailing Address - State:IL
Mailing Address - Zip Code:60172-4703
Mailing Address - Country:US
Mailing Address - Phone:815-922-4269
Mailing Address - Fax:
Practice Address - Street 1:1443 ASHBURY LN W
Practice Address - Street 2:
Practice Address - City:ROSELLE
Practice Address - State:IL
Practice Address - Zip Code:60172-4703
Practice Address - Country:US
Practice Address - Phone:815-922-4269
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-15
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070012751225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist