Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 226300000X | Kinesiotherapist | 1522 | IA |
NPI | 1588778740 |
---|---|
Provider Name | Michelle Petersen |
First Address | Belton, TX 76513-7085 |
Second Address | Temple, TX 76504-7451 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 17/08/2006 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1522 | (02) | TX |