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NPI Code Detail

MEDICARE: PATRICE KNIGHTLY PETERSON P.T.

MEDICARE: PATRICE KNIGHTLY PETERSON P.T.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1225100000XPhysical Therapist006391CT

General Provider Information

NPI Number : 1417132416
Entity Type Code : Individual
Provider Name (Legal Business Name) : PATRICE KNIGHTLY PETERSON P.T.
Provider Business Mailing Address
First Line : 41 GLENWOOD RD
Second Line :
City : WEST HARTFORD
State : CT
Zip : 06107-1506
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 256 NEW BRITAIN AVE
Second Line :
City : NEWINGTON
State : CT
Zip : 06111-4416
Country : US
Telephone Number : 860-666-5689
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/08/2008
Last Update Date : 01/02/2014

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