Provider Demographics
NPI:1144639097
Name:PETERSEN, NEENA
Entity type:Individual
Prefix:
First Name:NEENA
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NEENA
Other - Middle Name:
Other - Last Name:CAPOLUPO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:403 BEN OAKS DR W
Mailing Address - Street 2:
Mailing Address - City:SEVERNA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:21146-2208
Mailing Address - Country:US
Mailing Address - Phone:760-846-2295
Mailing Address - Fax:
Practice Address - Street 1:403 BEN OAKS DR W
Practice Address - Street 2:
Practice Address - City:SEVERNA PARK
Practice Address - State:MD
Practice Address - Zip Code:21146-2208
Practice Address - Country:US
Practice Address - Phone:760-846-2295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-05
Last Update Date:2022-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD26443225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist