Healthcare Provider Details

I. General information

NPI: 1467471102
Provider Name (Legal Business Name): CHERYL M PETERSEN PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1085 NIAGARA LN
PORT WASHINGTON WI
53074-1766
US

IV. Provider business mailing address

1085 NIAGARA LN
PORT WASHINGTON WI
53074-1766
US

V. Phone/Fax

Practice location:
  • Phone: 262-268-7260
  • Fax:
Mailing address:
  • Phone: 262-268-7260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number9865-024
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: