Provider Demographics
NPI:1376629360
Name:PETERSON, LYNDA LEE (MA-CCC/SLP)
Entity Type:Individual
Prefix:
First Name:LYNDA
Middle Name:LEE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MA-CCC/SLP
Other - Prefix:
Other - First Name:LINDA
Other - Middle Name:GAYLE
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA-CCC/SLP
Mailing Address - Street 1:9912-300TH AVE. N.
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:MN
Mailing Address - Zip Code:55371
Mailing Address - Country:US
Mailing Address - Phone:763-389-5548
Mailing Address - Fax:
Practice Address - Street 1:1891 STATION PKWY NW
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MN
Practice Address - Zip Code:55304-3341
Practice Address - Country:US
Practice Address - Phone:763-755-4275
Practice Address - Fax:763-755-4261
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6329235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist