Individual
CAMILLE DIMONTE PETERSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
P.T., DPT
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
4377-024
WI
225100000X
Physical Therapist
Primary
5501004807
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
40203800
MEDICAID
WI
05
—
4673910
—
MI
Enumeration date
09/11/2006
Last updated
04/28/2009
Update your record
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