Provider Demographics
NPI:1497188387
Name:PETERSON SPEECH THERAPY
Entity Type:Organization
Organization Name:PETERSON SPEECH THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARISSA
Authorized Official - Middle Name:LYNNE
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MA/CCC-SLP
Authorized Official - Phone:208-757-8553
Mailing Address - Street 1:545 LINCOLN DR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-4118
Mailing Address - Country:US
Mailing Address - Phone:208-757-8553
Mailing Address - Fax:
Practice Address - Street 1:545 LINCOLN DR
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-4118
Practice Address - Country:US
Practice Address - Phone:208-757-8553
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-14
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty