Provider Demographics
NPI:1659448272
Name:ADRIENNE PETERS CCC PA
Entity Type:Organization
Organization Name:ADRIENNE PETERS CCC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARYANNE
Authorized Official - Middle Name:A
Authorized Official - Last Name:GOLDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-448-7101
Mailing Address - Street 1:2645 SW 37TH AVE
Mailing Address - Street 2:SUITE 304
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33133
Mailing Address - Country:US
Mailing Address - Phone:305-448-7101
Mailing Address - Fax:305-442-8730
Practice Address - Street 1:2645 SW 37TH AVE
Practice Address - Street 2:SUITE 304
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33133
Practice Address - Country:US
Practice Address - Phone:305-448-7101
Practice Address - Fax:305-442-8730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 1190235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL887325900Medicaid