Basic Information
| Provider Information | |||||||||
| NPI: | 1497193866 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSEN | ||||||||
| FirstName: | PRISCILLA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 621 N 2ND ST | ||||||||
| Address2: | |||||||||
| City: | ALHAMBRA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 918011316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263431757 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10428 LOWER AZUSA RD | ||||||||
| Address2: | |||||||||
| City: | EL MONTE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917311208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6266520755 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2013 | ||||||||
| LastUpdateDate: | 06/07/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225400000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner |
No ID Information.