Healthcare Provider Details

I. General information

NPI: 1295008761
Provider Name (Legal Business Name): BRETT WILLIAM PETERSEN PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2012
Last Update Date: 03/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5805 NEAL AVE N
OAK PARK HEIGHTS MN
55082-2177
US

IV. Provider business mailing address

4200 DAHLBERG DR SUITE 300
GOLDEN VALLEY MN
55422-4840
US

V. Phone/Fax

Practice location:
  • Phone: 651-439-8807
  • Fax: 651-439-0232
Mailing address:
  • Phone: 952-512-5600
  • Fax: 952-512-5651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224Y00000X
TaxonomyClinical Exercise Physiologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number8649
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: