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General NPI Number Information
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NPI Number | 1235508581
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Entity Type | Individual
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Provider Name | SUSAN PETERSEN M.P.T
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Gender | Female
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Dates
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Enumeration Date | 09/16/2015
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Last Update Date | 09/16/2015
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Provider Practice Location Address
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Address Line | 2012 PHALAROPE CT
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City | COSTA MESA
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State | CA
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Zip | 92626-4734
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Country | US
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Telephone | 714-580-2868
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Fax | 714-241-1007
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Provider Business Mailing Address
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Address Line | 2012 PHALAROPE CT
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City | COSTA MESA
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State | CA
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Zip | 92626-4734
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Country | US
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Telephone | 714-580-2868
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Fax | 714-241-1007
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 18793
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License Number State | CA
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