Provider Demographics
NPI:1669715934
Name:PETERSON, MADDISON PAIGE
Entity type:Individual
Prefix:
First Name:MADDISON
Middle Name:PAIGE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1313 S ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:NE
Mailing Address - Zip Code:69336-2563
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1313 S ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:NE
Practice Address - Zip Code:69336-2563
Practice Address - Country:US
Practice Address - Phone:308-262-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-04
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE901043225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist