Provider Demographics
NPI:1609924257
Name:PETERS, BECKY JEAN (MA CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:BECKY
Middle Name:JEAN
Last Name:PETERS
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 N COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201-3307
Mailing Address - Country:US
Mailing Address - Phone:480-472-0727
Mailing Address - Fax:480-472-0705
Practice Address - Street 1:1645 N STERLING
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85207-2922
Practice Address - Country:US
Practice Address - Phone:480-472-8613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0023235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ801185Medicaid