Provider Demographics
NPI:1326398660
Name:PETERSEN, KIRSTEN E (MA, CCC-SLP, TSLD,BE)
Entity Type:Individual
Prefix:MISS
First Name:KIRSTEN
Middle Name:E
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:MA, CCC-SLP, TSLD,BE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 MULBERRY AVE
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-1830
Mailing Address - Country:US
Mailing Address - Phone:516-474-1766
Mailing Address - Fax:
Practice Address - Street 1:40 MULBERRY AVE
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-1830
Practice Address - Country:US
Practice Address - Phone:516-474-1766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021322-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist