Basic Information
| Provider Information | |||||||||
| NPI: | 1225596950 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | MICHELLE | ||||||||
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| OtherLastName: | HALPIN | ||||||||
| OtherFirstName: | LAURA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 607 LITCHFIELD ROAD | ||||||||
| Address2: | |||||||||
| City: | GILLESPIE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62033 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 607 LITCHFIELD ROAD | ||||||||
| Address2: | |||||||||
| City: | GILLESPIE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172804405 | ||||||||
| FaxNumber: | 2172804406 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2019 | ||||||||
| LastUpdateDate: | 10/20/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.