Basic Information
| Provider Information | |||||||||
| NPI: | 1689344038 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 842 SHERWOOD RD | ||||||||
| Address2: | |||||||||
| City: | PITTSBURGH | ||||||||
| State: | PA | ||||||||
| PostalCode: | 152213724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4405960469 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6785 BUSINESS PKWY | ||||||||
| Address2: | |||||||||
| City: | ELKRIDGE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210756353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105798999 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2021 | ||||||||
| LastUpdateDate: | 09/25/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 10840 | SC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 10840 | 01 | SC | PHYSICAL THERAPY LICENSE | OTHER | 28677 | 01 | MD | PHYSICAL THERAPY LICENSE | OTHER |