Healthcare Provider Details

I. General information

NPI: 1114230547
Provider Name (Legal Business Name): HOLLY ANNE PETERSEN PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2010
Last Update Date: 09/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

186 SUMMER ST
KINGSTON MA
02364-1282
US

IV. Provider business mailing address

535 S MAIN ST 2ND FLOOR
RANDOLPH MA
02368-5261
US

V. Phone/Fax

Practice location:
  • Phone: 781-585-8588
  • Fax: 781-585-1279
Mailing address:
  • Phone: 781-961-3370
  • Fax: 781-767-7531

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number19130
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: