Provider Demographics
NPI:1003174178
Name:PETER, RENAE (MS, SLP-CCC)
Entity Type:Individual
Prefix:MS
First Name:RENAE
Middle Name:
Last Name:PETER
Suffix:
Gender:F
Credentials:MS, SLP-CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12363 LAGUNA DR
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-9040
Mailing Address - Country:US
Mailing Address - Phone:618-263-2385
Mailing Address - Fax:
Practice Address - Street 1:12363 LAGUNA DR
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-9040
Practice Address - Country:US
Practice Address - Phone:618-263-2385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-26
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146010152235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist