Provider Demographics
NPI:1346930294
Name:PETERSON, RESHICKA MONE'
Entity Type:Individual
Prefix:
First Name:RESHICKA
Middle Name:MONE'
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RESHICKA
Other - Middle Name:MONE'
Other - Last Name:HAWKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1413 NW 188TH ST
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73012-6209
Mailing Address - Country:US
Mailing Address - Phone:918-728-4077
Mailing Address - Fax:
Practice Address - Street 1:4401 W MEMORIAL RD STE 125
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73134-1787
Practice Address - Country:US
Practice Address - Phone:405-752-3060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-12
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5452235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist