Basic Information
| Provider Information | |||||||||
| NPI: | 1841507324 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | WESLEY | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1830 HANLEY RD | ||||||||
| Address2: | |||||||||
| City: | HUDSON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540169368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153861155 | ||||||||
| FaxNumber: | 7153861105 | ||||||||
| Practice Location | |||||||||
| Address1: | 1830 HANLEY RD | ||||||||
| Address2: | |||||||||
| City: | HUDSON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540169368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153861155 | ||||||||
| FaxNumber: | 7153861105 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2010 | ||||||||
| LastUpdateDate: | 04/27/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 8633 | MN | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 11914-24 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.