Basic Information
| Provider Information | |||||||||
| NPI: | 1710158563 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | LENA | ||||||||
| MiddleName: | CAROLYN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MS, OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1860 W WINCHESTER RD | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | LIBERTYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600485351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475739486 | ||||||||
| FaxNumber: | 8475496139 | ||||||||
| Practice Location | |||||||||
| Address1: | 1860 W WINCHESTER RD | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | LIBERTYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600485351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475739486 | ||||||||
| FaxNumber: | 8475496139 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2008 | ||||||||
| LastUpdateDate: | 03/20/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XP0200X | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics |
No ID Information.