Provider Demographics
NPI:1598161929
Name:PETERSON, JOSHUA (HIS)
Entity Type:Individual
Prefix:MR
First Name:JOSHUA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 HUGH HOWELL RD STE 340
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-4719
Mailing Address - Country:US
Mailing Address - Phone:770-696-9239
Mailing Address - Fax:678-691-2187
Practice Address - Street 1:5620 CRAWFORDSVILLE RD STE Q
Practice Address - Street 2:
Practice Address - City:SPEEDWAY
Practice Address - State:IN
Practice Address - Zip Code:46224-3726
Practice Address - Country:US
Practice Address - Phone:317-388-8144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-12
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN17001427A237700000X
GA000934237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist