=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790828531
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TODD PETERSON ATC, PTA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2007
-----------------------------------------------------
Last Update Date | 09/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 120 ERIE CANAL DR
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14626-4607
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-225-6296
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O. BOX 195
-----------------------------------------------------
City | EAST PEMBROKE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14056
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-762-8883
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 003649-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 001176-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------