MEDICARE: ILIANA PETERSEN

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
1	225X00000X	Occupational Therapist	4185	CA

General Provider Information

NPI Number	:	1689087223
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ILIANA PETERSEN

Provider Business Mailing Address
First Line	:	335 ROLLING HILLS AVE
Second Line	:
City	:	SAN MATEO
State	:	CA
Zip	:	94403-4320
Country	:	US
Telephone Number	:	650-291-1527
Fax Number	:

Provider Business Practice Location Address
First Line	:	1275 CRANE ST
Second Line	:
City	:	MENLO PARK
State	:	CA
Zip	:	94025-4212
Country	:	US
Telephone Number	:	650-322-6501
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/10/2014
Last Update Date	:	06/10/2014

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Directions to “ ILIANA PETERSEN ” Practice Location

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