Basic Information
| Provider Information | |||||||||
| NPI: | 1932374147 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSEN | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | ELISE | ||||||||
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| Credential: | OT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1301 EAST BIDWELL STREET | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | FOLSOM | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9169835915 | ||||||||
| FaxNumber: | 9169835925 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 E BIDWELL ST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | FOLSOM | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956303452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9169835915 | ||||||||
| FaxNumber: | 9169835925 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2008 | ||||||||
| LastUpdateDate: | 04/29/2008 | ||||||||
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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 | 225X00000X | 6047 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.