Provider Demographics
NPI:1588640304
Name:PETERSON, HEATHER ALYSA (MS SLP LLL)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:ALYSA
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MS SLP LLL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1824 BELMONT RD NW
Mailing Address - Street 2:#31
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20009
Mailing Address - Country:US
Mailing Address - Phone:202-425-6874
Mailing Address - Fax:703-922-0638
Practice Address - Street 1:6506 LOISDALE RD
Practice Address - Street 2:SUITE #300
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22150
Practice Address - Country:US
Practice Address - Phone:703-924-4183
Practice Address - Fax:703-922-0638
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA12074933235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist