Provider Demographics
NPI:1225313679
Name:PETERSON, SUSAN YVONNE
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:YVONNE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:SUSAN
Other - Middle Name:YVONNE
Other - Last Name:BAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3031 CAMINO CALANDRIA
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-4534
Mailing Address - Country:US
Mailing Address - Phone:805-493-2229
Mailing Address - Fax:
Practice Address - Street 1:10730 HENDERSON RD
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93004-1832
Practice Address - Country:US
Practice Address - Phone:805-647-1141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-18
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8474235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist