Healthcare Provider Details

I. General information

NPI: 1407970726
Provider Name (Legal Business Name): LORENE MAE PETERSON OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 UNIVERSITY DR S
FARGO ND
58103-4940
US

IV. Provider business mailing address

4519 3RD ST S
MOORHEAD MN
56560-6729
US

V. Phone/Fax

Practice location:
  • Phone: 701-280-4070
  • Fax:
Mailing address:
  • Phone: 218-236-8009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License Number288
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License Number101750
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License Number3838
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: