Provider Demographics
NPI:1346433653
Name:PETERSON, NINA E (CCC-SP)
Entity Type:Individual
Prefix:
First Name:NINA
Middle Name:E
Last Name:PETERSON
Suffix:
Gender:F
Credentials:CCC-SP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4541 LAKE WASHINGTON BLVD NE
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98033-7628
Mailing Address - Country:US
Mailing Address - Phone:425-803-1886
Mailing Address - Fax:
Practice Address - Street 1:4541 LAKE WASHINGTON BLVD NE
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98033-7628
Practice Address - Country:US
Practice Address - Phone:425-803-1886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-20
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist