Healthcare Provider Details

I. General information

NPI: 1851418248
Provider Name (Legal Business Name): COLLEEN PETERSON MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8015 LAWNDALE AVE
PHILADELPHIA PA
19111-1507
US

IV. Provider business mailing address

1218 MELODY LN
SOUTHAMPTON PA
18966-4320
US

V. Phone/Fax

Practice location:
  • Phone: 215-725-2525
  • Fax:
Mailing address:
  • Phone: 215-364-5102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT003064E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: