Provider Demographics
NPI:1083750996
Name:PETERSEN, ELIZA S (AUD, CCCA)
Entity Type:Individual
Prefix:DR
First Name:ELIZA
Middle Name:S
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:AUD, CCCA
Other - Prefix:
Other - First Name:ELIZA
Other - Middle Name:
Other - Last Name:SCHWAB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, CCCA, FAAA
Mailing Address - Street 1:1388 MOUNT MORIAH RD
Mailing Address - Street 2:
Mailing Address - City:LIVERMORE
Mailing Address - State:CO
Mailing Address - Zip Code:80536-9311
Mailing Address - Country:US
Mailing Address - Phone:307-745-5587
Mailing Address - Fax:877-515-1633
Practice Address - Street 1:2740 SHADOWMOON LN STE 417
Practice Address - Street 2:
Practice Address - City:DRIGGS
Practice Address - State:ID
Practice Address - Zip Code:83422-5083
Practice Address - Country:US
Practice Address - Phone:307-745-5587
Practice Address - Fax:877-515-1633
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYA-974231H00000X
IDAUD-1142231H00000X
IDAUD1142237600000X
WYA974237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807694600Medicaid
WY125563100Medicaid