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NPI Code Detail

MEDICARE: MRS. TEGAN CLEO PETERSEN

MEDICARE: MRS. TEGAN CLEO PETERSEN
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1106S00000XBehavior Technician

General Provider Information

NPI Number : 1336645258
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. TEGAN CLEO PETERSEN
Provider Business Mailing Address
First Line : 3307 BUTTERNUT DR
Second Line :
City : LOVELAND
State : CO
Zip : 80538-2617
Country : US
Telephone Number : 970-402-6349
Fax Number :
Provider Business Practice Location Address
First Line : 1613 PROSPECT PARK WAY STE 110
Second Line :
City : FORT COLLINS
State : CO
Zip : 80525-9707
Country : US
Telephone Number : 970-377-9401
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/30/2018
Last Update Date : 03/30/2018

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Directions to “ MRS. TEGAN CLEO PETERSEN ” Practice Location

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