Healthcare Provider Details

I. General information

NPI: 1316350077
Provider Name (Legal Business Name): PETERSON PHYSICAL THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2014
Last Update Date: 12/10/2020
Certification Date: 12/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

144 DRURY DR
LA PLATA MD
20646-4241
US

IV. Provider business mailing address

PO BOX 102
LA PLATA MD
20646-0102
US

V. Phone/Fax

Practice location:
  • Phone: 410-371-0337
  • Fax: 301-539-3814
Mailing address:
  • Phone: 301-539-3807
  • Fax: 301-539-3814

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number20342
License Number StateMD

VIII. Authorized Official

Name: MRS. SUSAN PETERSON
Title or Position: OWNER/CLINICIAN
Credential: P.T.
Phone: 410-371-0337