Provider Demographics
NPI:1952540767
Name:PETERSON, TRISHA M (PTA)
Entity Type:Individual
Prefix:MRS
First Name:TRISHA
Middle Name:M
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3271 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:EAST TROY
Mailing Address - State:WI
Mailing Address - Zip Code:53120-1147
Mailing Address - Country:US
Mailing Address - Phone:262-642-3995
Mailing Address - Fax:
Practice Address - Street 1:3271 NORTH ST
Practice Address - Street 2:
Practice Address - City:EAST TROY
Practice Address - State:WI
Practice Address - Zip Code:53120-1147
Practice Address - Country:US
Practice Address - Phone:262-642-3995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-18
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1388-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant