Provider Demographics
NPI:1376681718
Name:PETERS, ADRIENNE K (MED)
Entity Type:Individual
Prefix:MRS
First Name:ADRIENNE
Middle Name:K
Last Name:PETERS
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2645 SW 37TH AVE
Mailing Address - Street 2:#304
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33133-2754
Mailing Address - Country:US
Mailing Address - Phone:305-448-7101
Mailing Address - Fax:305-442-8730
Practice Address - Street 1:2645 SW 37TH AVE
Practice Address - Street 2:#304
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33133-2754
Practice Address - Country:US
Practice Address - Phone:305-448-7101
Practice Address - Fax:305-442-8730
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA1190235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSA1190OtherSTATE LICENSE
FL880481800Medicaid