Healthcare Provider Details

I. General information

NPI: 1851323067
Provider Name (Legal Business Name): CONSTANCE V PETERSON PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

187 GALLAHER RD
KINGSTON TN
37763-4721
US

IV. Provider business mailing address

211 CENTER PARK DRIVE SUITE 3060
KNOXVILLE TN
37922
US

V. Phone/Fax

Practice location:
  • Phone: 865-376-4620
  • Fax: 865-376-1759
Mailing address:
  • Phone: 865-966-8545
  • Fax: 865-966-3936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number1095
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: