1619169901 NPI number — MRS. MICHELLE PETERSON DEVELOPMENTAL THERAP

Table of content: MRS. MICHELLE PETERSON DEVELOPMENTAL THERAP (NPI 1619169901)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619169901 NPI number — MRS. MICHELLE PETERSON DEVELOPMENTAL THERAP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSON
Provider First Name:
MICHELLE
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
DEVELOPMENTAL THERAP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619169901
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/10/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
579 RIFORD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLEN ELLYN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60137-4236
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-858-2336
Provider Business Mailing Address Fax Number:
630-942-0377

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
579 RIFORD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLEN ELLYN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60137-4236
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-858-2336
Provider Business Practice Location Address Fax Number:
630-942-0377
Provider Enumeration Date:
08/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 222Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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