Provider Demographics
NPI:1063661916
Name:PETERSEN, MARY ALICE (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ALICE
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 STAMPEDE ST
Mailing Address - Street 2:
Mailing Address - City:NEWCASTLE
Mailing Address - State:WY
Mailing Address - Zip Code:82701-3037
Mailing Address - Country:US
Mailing Address - Phone:307-746-4560
Mailing Address - Fax:
Practice Address - Street 1:104 STAMPEDE ST
Practice Address - Street 2:
Practice Address - City:NEWCASTLE
Practice Address - State:WY
Practice Address - Zip Code:82701-3037
Practice Address - Country:US
Practice Address - Phone:307-746-4560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-16
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY#SP-391235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist