Provider Demographics
NPI:1265861108
Name:PETERSEN, CAROLINE ANNE
Entity Type:Individual
Prefix:MRS
First Name:CAROLINE
Middle Name:ANNE
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2107 AVERY RD E
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:NE
Mailing Address - Zip Code:68005-4617
Mailing Address - Country:US
Mailing Address - Phone:402-293-4467
Mailing Address - Fax:
Practice Address - Street 1:2107 AVERY RD E
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:NE
Practice Address - Zip Code:68005-4617
Practice Address - Country:US
Practice Address - Phone:402-293-4467
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-01
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2013009812235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist