Provider Demographics
NPI:1205453552
Name:PEDERSON, TEDIJO (ATC)
Entity type:Individual
Prefix:
First Name:TEDIJO
Middle Name:
Last Name:PEDERSON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2034 COLT DR
Mailing Address - Street 2:P.O. BOX 55
Mailing Address - City:VICTOR
Mailing Address - State:MT
Mailing Address - Zip Code:59875
Mailing Address - Country:US
Mailing Address - Phone:406-930-2150
Mailing Address - Fax:
Practice Address - Street 1:400 S CLARK ST
Practice Address - Street 2:
Practice Address - City:BUTTE
Practice Address - State:MT
Practice Address - Zip Code:59701-2328
Practice Address - Country:US
Practice Address - Phone:406-723-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-02
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MTATR-LAT-LIC-25082255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program