Healthcare Provider Details

I. General information

NPI: 1942429873
Provider Name (Legal Business Name): MARY ANN PETERSON PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2117 GENERAL BOOTH BLVD
VIRGINIA BEACH VA
23454-5803
US

IV. Provider business mailing address

3440 ARCHER CT
VIRGINIA BEACH VA
23452-5911
US

V. Phone/Fax

Practice location:
  • Phone: 757-430-8739
  • Fax:
Mailing address:
  • Phone: 757-498-9203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number2305002139
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: