Provider Demographics
NPI:1528898582
Name:PETERSON, CHLOE LYNN
Entity type:Individual
Prefix:
First Name:CHLOE
Middle Name:LYNN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 E MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:WOODVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54028-9513
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2901 FORBES AVE
Practice Address - Street 2:
Practice Address - City:MENOMONIE
Practice Address - State:WI
Practice Address - Zip Code:54751-1519
Practice Address - Country:US
Practice Address - Phone:715-232-2661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-05
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7182-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant