Basic Information
| Provider Information | |||||||||
| NPI: | 1760771109 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSEN | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | MARK | ||||||||
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| Credential: | OTD, OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 249 E OCEAN BLVD STE 440 | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908024806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8888087838 | ||||||||
| FaxNumber: | 8666203943 | ||||||||
| Practice Location | |||||||||
| Address1: | 249 E OCEAN BLVD STE 440 | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908024806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8888087838 | ||||||||
| FaxNumber: | 8666203943 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2011 | ||||||||
| LastUpdateDate: | 04/06/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 10906 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.