Provider Demographics
NPI:1730403213
Name:PETERSON, MARY E (PT)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:E
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:E
Other - Last Name:BENNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:11140 THOMPSON AVE
Mailing Address - Street 2:
Mailing Address - City:LENEXA
Mailing Address - State:KS
Mailing Address - Zip Code:66219-2301
Mailing Address - Country:US
Mailing Address - Phone:913-789-4075
Mailing Address - Fax:913-888-1728
Practice Address - Street 1:11140 THOMPSON AVE
Practice Address - Street 2:
Practice Address - City:LENEXA
Practice Address - State:KS
Practice Address - Zip Code:66219-2301
Practice Address - Country:US
Practice Address - Phone:913-789-4075
Practice Address - Fax:913-888-1728
Is Sole Proprietor?:No
Enumeration Date:2010-03-26
Last Update Date:2010-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1101341225100000X
MORO919225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist