Provider Demographics
NPI:1881692523
Name:PETERSON, CHAD M (PT)
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:M
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 1:823 BELKNAP ST
Mailing Address - Street 2:STE 104
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-2974
Mailing Address - Country:US
Mailing Address - Phone:715-394-6355
Mailing Address - Fax:715-394-2191
Practice Address - Street 1:823 BELKNAP ST
Practice Address - Street 2:STE 104
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-2974
Practice Address - Country:US
Practice Address - Phone:715-394-6355
Practice Address - Fax:715-394-2191
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6767225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist