Healthcare Provider Details

I. General information

NPI: 1427536614
Provider Name (Legal Business Name): PETERSON THERAPY SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2018
Last Update Date: 08/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

545 LINCOLN DR
IDAHO FALLS ID
83401
US

IV. Provider business mailing address

545 LINCOLN DR
IDAHO FALLS ID
83401-4118
US

V. Phone/Fax

Practice location:
  • Phone: 208-584-1141
  • Fax: 888-501-2591
Mailing address:
  • Phone: 208-584-1141
  • Fax: 888-501-2591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name: MARISSA PETERSON
Title or Position: OWNER
Credential: MA/CCC-SLP
Phone: 208-584-1141