Provider Demographics
NPI:1538591649
Name:PETERSON, LAUREN COLLIER (PT, DPT)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:COLLIER
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1808 MULHOLLAND DR
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73012-4120
Mailing Address - Country:US
Mailing Address - Phone:405-230-6330
Mailing Address - Fax:
Practice Address - Street 1:7415 N MAY AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116
Practice Address - Country:US
Practice Address - Phone:405-400-8909
Practice Address - Fax:405-400-8949
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-31
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE3254225100000X, 2251X0800X
IA076040225100000X
OK5393225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE09856254001Medicaid