Provider Demographics
NPI:1598211195
Name:PETERSON, MEGAN ANNE
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:ANNE
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 1:318 SAMUEL DRIVE
Mailing Address - Street 2:408
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53717
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 HIGHLAND AVE
Practice Address - Street 2:MAIL STOP 2424
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53792-2424
Practice Address - Country:US
Practice Address - Phone:608-262-8060
Practice Address - Fax:608-262-7679
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4334-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist