Provider Demographics
NPI:1548671167
Name:PETERSON, KATHERINE ANNE (DT)
Entity type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:ANNE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1130 JONESBORO QUARRY RD
Mailing Address - Street 2:
Mailing Address - City:ANNA
Mailing Address - State:IL
Mailing Address - Zip Code:62906-3777
Mailing Address - Country:US
Mailing Address - Phone:618-322-4338
Mailing Address - Fax:
Practice Address - Street 1:1130 JONESBORO QUARRY RD
Practice Address - Street 2:
Practice Address - City:ANNA
Practice Address - State:IL
Practice Address - Zip Code:62906-3777
Practice Address - Country:US
Practice Address - Phone:618-322-4338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-16
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist