MEDICARE: DR. MIKELLE MARIE PETERSON PT, DPT

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	225100000X	Physical Therapist	7694	CO

General Provider Information

NPI Number	:	1861476574
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MIKELLE MARIE PETERSON PT, DPT

Provider Business Mailing Address
First Line	:	29670 COUNTY ROAD 372A
Second Line	:
City	:	BUENA VISTA
State	:	CO
Zip	:	81211-9704
Country	:	US
Telephone Number	:	303-862-1840
Fax Number	:

Provider Business Practice Location Address
First Line	:	29670 COUNTY ROAD 372A
Second Line	:
City	:	BUENA VISTA
State	:	CO
Zip	:	81211-9704
Country	:	US
Telephone Number	:	303-862-1840
Fax Number	:

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

Provider Enumeration Date	:	12/06/2005
Last Update Date	:	10/01/2018

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