Provider Demographics
NPI:1164197570
Name:PETERSON, MILLICENT ROSE (AUD, CCC-A)
Entity Type:Individual
Prefix:DR
First Name:MILLICENT
Middle Name:ROSE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:AUD, CCC-A
Other - Prefix:DR
Other - First Name:MILLICENT
Other - Middle Name:ROSE
Other - Last Name:QUEVEDO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD, CCC-A
Mailing Address - Street 1:55 TERRACE LN
Mailing Address - Street 2:
Mailing Address - City:BLAUVELT
Mailing Address - State:NY
Mailing Address - Zip Code:10913-1333
Mailing Address - Country:US
Mailing Address - Phone:845-709-7167
Mailing Address - Fax:
Practice Address - Street 1:30 MATTHEWS ST STE 203
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:NY
Practice Address - Zip Code:10924-1985
Practice Address - Country:US
Practice Address - Phone:845-294-8544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-09
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YA00115300231H00000X
NY003037-01231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist