Healthcare Provider Details

I. General information

NPI: 1861701807
Provider Name (Legal Business Name): ELENA J. PETERSEN PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELENA ISAAC

II. Dates (important events)

Enumeration Date: 09/24/2010
Last Update Date: 12/04/2020
Certification Date: 12/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2935 S RECKER RD ATTN: SPED
GILBERT AZ
85295-7846
US

IV. Provider business mailing address

2935 S RECKER RD ATTN: SPED
GILBERT AZ
85295-7846
US

V. Phone/Fax

Practice location:
  • Phone: 480-279-7059
  • Fax:
Mailing address:
  • Phone: 480-279-7059
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number8935
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: