Healthcare Provider Details

I. General information

NPI: 1578673562
Provider Name (Legal Business Name): PETERSEN PHYSICAL THERAPY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 05/07/2020
Certification Date: 05/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1844 E BASELINE RD STE C5
TEMPE AZ
85283-1506
US

IV. Provider business mailing address

1844 E BASELINE RD STE C5
TEMPE AZ
85283-1506
US

V. Phone/Fax

Practice location:
  • Phone: 480-833-1005
  • Fax: 480-833-1312
Mailing address:
  • Phone: 480-833-1005
  • Fax: 480-833-1312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number StateAZ

VIII. Authorized Official

Name: ROBIN WACHTER
Title or Position: VP ADMINISTRATION
Credential:
Phone: 480-833-1005