Provider Demographics
NPI:1669633590
Name:PETERSON, MARISSA (MA/CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:PETERSON
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:PO BOX 2943
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-2943
Mailing Address - Country:US
Mailing Address - Phone:208-757-8553
Mailing Address - Fax:208-524-1929
Practice Address - Street 1:545 LINCOLN DR
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-4118
Practice Address - Country:US
Practice Address - Phone:208-757-8553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-23
Last Update Date:2009-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-1685235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist