Provider Demographics
NPI:1275603342
Name:PETERSON, LACY ANNETTE (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:LACY
Middle Name:ANNETTE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:MRS
Other - First Name:LACY
Other - Middle Name:ANNETTE
Other - Last Name:SHOEMAKER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:7112 S MINGO RD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-3201
Mailing Address - Country:US
Mailing Address - Phone:918-250-7093
Mailing Address - Fax:918-250-9976
Practice Address - Street 1:7112 S MINGO RD
Practice Address - Street 2:SUITE 108
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-3201
Practice Address - Country:US
Practice Address - Phone:918-250-7093
Practice Address - Fax:918-250-9976
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3230235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
12096911OtherASHA ACCOUNT NUMBER