Provider Demographics
NPI:1174775985
Name:PETERSON, BRETT MICHAEL (OTR/L)
Entity type:Individual
Prefix:MR
First Name:BRETT
Middle Name:MICHAEL
Last Name:PETERSON
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11432 SCOTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH EAST
Mailing Address - State:PA
Mailing Address - Zip Code:16428-3143
Mailing Address - Country:US
Mailing Address - Phone:814-725-0287
Mailing Address - Fax:
Practice Address - Street 1:3805 FIELD ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16511-2825
Practice Address - Country:US
Practice Address - Phone:814-898-5600
Practice Address - Fax:814-899-9829
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-13
Last Update Date:2008-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC004839L225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist