Provider Demographics
NPI:1619989548
Name:PETERSEN, MONICA (MS, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:MONICA
Middle Name:
Last Name:PETERSEN
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 1:2911 SANFORD CIR
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-4929
Mailing Address - Country:US
Mailing Address - Phone:501-416-4664
Mailing Address - Fax:
Practice Address - Street 1:2911 SANFORD CIR
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538-4929
Practice Address - Country:US
Practice Address - Phone:501-416-4664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
09135533235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR133710721Medicaid