Provider Demographics
NPI:1467112011
Name:PETERMAN, KALEY (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KALEY
Middle Name:
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 1:862 GLENNEYRE CIR
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-1231
Mailing Address - Country:US
Mailing Address - Phone:904-460-4951
Mailing Address - Fax:
Practice Address - Street 1:12627 SAN JOSE BLVD STE 803
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-8644
Practice Address - Country:US
Practice Address - Phone:904-460-4951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-22
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA13895235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist