Individual
MR. THEODORE WILLIAM PETERSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
O.T.R.
Contact information
Practice address
IDAHO STATE UNIVERSITY, CAMPUS BOX 8045, POCATELLO, ID 83209-0001
(208) 282-4631
Mailing address
2080 ARDELLA DR, POCATELLO, ID 83201-2615
(208) 904-1574
Taxonomy
Speciality
Code
Description
License number
State
225X00000X
Occupational Therapist
00800
IA
225X00000X
Occupational Therapist
Primary
OT-886
ID
Other
Enumeration date
11/15/2006
Last updated
08/18/2008
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