Provider Demographics
NPI:1376321612
Name:PETERSON, MAXINE R (MS CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:MAXINE
Middle Name:R
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2556 FREDERICK DOUGLASS BLVD APT B
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10030-3039
Mailing Address - Country:US
Mailing Address - Phone:917-685-8246
Mailing Address - Fax:
Practice Address - Street 1:270 E 167TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10456-4066
Practice Address - Country:US
Practice Address - Phone:718-293-9048
Practice Address - Fax:718-293-9748
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-18
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY235Z00000X
NY033601235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist