Provider Demographics
NPI:1053458364
Name:PETERSON, TERI KAMINSKI
Entity Type:Individual
Prefix:
First Name:TERI
Middle Name:KAMINSKI
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TERI
Other - Middle Name:ANN
Other - Last Name:KAMINSKI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:820 ROY ST
Mailing Address - Street 2:
Mailing Address - City:ORTONVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:56278-1138
Mailing Address - Country:US
Mailing Address - Phone:320-839-4271
Mailing Address - Fax:
Practice Address - Street 1:15620 EDGEWOOD DR STE 240
Practice Address - Street 2:
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56425
Practice Address - Country:US
Practice Address - Phone:218-454-7012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2010-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5504235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist