MEDICARE: MRS. PAULA L PETERSON PT

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
1	225100000X	Physical Therapist	PT871	TN
2	208100000X	Physical Medicine & Rehabilitation Physician	PT000000871	TN

General Provider Information

NPI Number	:	1972538619
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. PAULA L PETERSON PT

Provider Business Mailing Address
First Line	:	3525 KEITH ST NW
Second Line	:	SUITE M
City	:	CLEVELAND
State	:	TN
Zip	:	37312-4354
Country	:	US
Telephone Number	:	423-479-7800
Fax Number	:	423-479-2849

Provider Business Practice Location Address
First Line	:	3525 KEITH STREET NW
Second Line	:	SUITE M
City	:	CLEVELAND
State	:	TN
Zip	:	37312-4354
Country	:	US
Telephone Number	:	423-479-7800
Fax Number	:	423-479-2849

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/11/2006
Last Update Date	:	08/19/2009

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