Provider Demographics
NPI:1235346065
Name:PEDERSON, HEATHER L (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:L
Last Name:PEDERSON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18179 W OCOTILLO AVE
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-5074
Mailing Address - Country:US
Mailing Address - Phone:602-357-5926
Mailing Address - Fax:
Practice Address - Street 1:210 S 6TH ST
Practice Address - Street 2:
Practice Address - City:BUCKEYE
Practice Address - State:AZ
Practice Address - Zip Code:85326-2830
Practice Address - Country:US
Practice Address - Phone:623-386-4487
Practice Address - Fax:623-386-6063
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4778235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ09145517OtherASHA CERTIFIED MEMBER
AZ4778OtherSLP - REGULAR LICENSE