Provider Demographics
NPI:1396218657
Name:PETERMAN, MADISON LOU (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:LOU
Last Name:PETERMAN
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 1:845 5TH AVE APT 207
Mailing Address - Street 2:
Mailing Address - City:DUNCANSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16635-1405
Mailing Address - Country:US
Mailing Address - Phone:814-762-6404
Mailing Address - Fax:
Practice Address - Street 1:700 CAYUGA AVE
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16602-4303
Practice Address - Country:US
Practice Address - Phone:814-946-0471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-09
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL014366235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist