Provider Demographics
NPI:1497154033
Name:PETERSON, LISA
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 N FOSTER ST
Mailing Address - Street 2:PO BOX 117
Mailing Address - City:CENTER
Mailing Address - State:MO
Mailing Address - Zip Code:63436-1026
Mailing Address - Country:US
Mailing Address - Phone:573-267-3963
Mailing Address - Fax:
Practice Address - Street 1:407 N FOSTER ST
Practice Address - Street 2:
Practice Address - City:CENTER
Practice Address - State:MO
Practice Address - Zip Code:63436-1026
Practice Address - Country:US
Practice Address - Phone:573-267-3963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-20
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0347894235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO0347894OtherMISSOURI DEPARTMENT OF EDUCATION-TEACHING CERTIFICATE