Basic Information
| Provider Information | |||||||||
| NPI: | 1932325172 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | CHRISTINE | ||||||||
| MiddleName: | JO | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2114 HAMMOND AVE | ||||||||
| Address2: | |||||||||
| City: | SUPERIOR | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548805038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153949384 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1800 NEW YORK AVE | ||||||||
| Address2: | |||||||||
| City: | SUPERIOR | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548802008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153945591 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 225100000X | 4841-024 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.