Provider Demographics
NPI:1417147760
Name:PETERSON, KEESHA L (M S CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KEESHA
Middle Name:L
Last Name:PETERSON
Suffix:
Gender:F
Credentials:M S CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1418 COLLEGE DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT CARMEL
Mailing Address - State:IL
Mailing Address - Zip Code:62863-2638
Mailing Address - Country:US
Mailing Address - Phone:618-263-6343
Mailing Address - Fax:618-263-6477
Practice Address - Street 1:1418 COLLEGE DRIVE
Practice Address - Street 2:PHYSICAL MEDICINE DEPARTMENT
Practice Address - City:MOUNT CARMEL
Practice Address - State:IL
Practice Address - Zip Code:62863
Practice Address - Country:US
Practice Address - Phone:618-263-6343
Practice Address - Fax:618-263-6477
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-01
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22003291A235Z00000X
IL146-005206235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist