Provider Demographics
NPI:1568568442
Name:PETERSON, SALLY ANN (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:ANN
Last Name:PETERSON
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 1:214 GLENMONT RD
Mailing Address - Street 2:
Mailing Address - City:RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54022-8018
Mailing Address - Country:US
Mailing Address - Phone:715-425-8975
Mailing Address - Fax:
Practice Address - Street 1:2705 ENLOE ST
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-8173
Practice Address - Country:US
Practice Address - Phone:715-386-2128
Practice Address - Fax:715-386-6119
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1768235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
641671046996OtherPREFERRED ONE
7038035OtherAETNA
MN98G68PEOtherMN BCBS
WI42626000Medicaid
4607091OtherMEDICA
15665OtherHEALTH PARTNERS