Provider Demographics
NPI:1548659451
Name:PETERSON, STEPHEN (PT)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:746 S MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:FALLBROOK
Mailing Address - State:CA
Mailing Address - Zip Code:92028-3333
Mailing Address - Country:US
Mailing Address - Phone:760-728-8999
Mailing Address - Fax:
Practice Address - Street 1:746 S MAIN AVE
Practice Address - Street 2:
Practice Address - City:FALLBROOK
Practice Address - State:CA
Practice Address - Zip Code:92028-3333
Practice Address - Country:US
Practice Address - Phone:760-728-8999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-15
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT10913225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist