Provider Demographics
NPI:1144734013
Name:PETERSON, HAZEL DIANE (ATC)
Entity type:Individual
Prefix:
First Name:HAZEL
Middle Name:DIANE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:HAZEL
Other - Middle Name:DIANE
Other - Last Name:REYES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:6055 NESTER WAY
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80922-1853
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1590 W FILLMORE ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80904-1104
Practice Address - Country:US
Practice Address - Phone:719-641-2898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-29
Last Update Date:2017-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAT.00011402255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer