Provider Demographics
NPI:1255305850
Name:PETERSEN, IAN B (ATC-L)
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:B
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:ATC-L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14720 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:OAK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60452-1268
Mailing Address - Country:US
Mailing Address - Phone:219-617-5253
Mailing Address - Fax:
Practice Address - Street 1:345 TAFT ROAD
Practice Address - Street 2:
Practice Address - City:SOUTH HOLLAND
Practice Address - State:IL
Practice Address - Zip Code:60473
Practice Address - Country:US
Practice Address - Phone:708-596-0107
Practice Address - Fax:708-671-0767
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer