Healthcare Provider Details

I. General information

NPI: 1306574884
Provider Name (Legal Business Name): TALIA PETERSEN DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2022
Last Update Date: 08/11/2022
Certification Date: 08/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 KANANI RD
KIHEI HI
96753-6805
US

IV. Provider business mailing address

977 SLATE DR
SANTA ROSA CA
95405-5592
US

V. Phone/Fax

Practice location:
  • Phone: 808-633-4480
  • Fax:
Mailing address:
  • Phone: 707-280-4533
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5509
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: