Provider Demographics
NPI:1679770119
Name:PETERS, TONYA SUE (SLP)
Entity Type:Individual
Prefix:MRS
First Name:TONYA
Middle Name:SUE
Last Name:PETERS
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5611 MACON COUNTY LINE RD
Mailing Address - Street 2:
Mailing Address - City:ILLIOPOLIS
Mailing Address - State:IL
Mailing Address - Zip Code:62539-3544
Mailing Address - Country:US
Mailing Address - Phone:217-486-5511
Mailing Address - Fax:
Practice Address - Street 1:1800 E LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-3810
Practice Address - Country:US
Practice Address - Phone:217-464-2415
Practice Address - Fax:217-464-1633
Is Sole Proprietor?:No
Enumeration Date:2007-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist