Provider Demographics
NPI:1689808065
Name:PETERSON, EILEEN M (MS,BOARD CERTIFIED)
Entity Type:Individual
Prefix:MRS
First Name:EILEEN
Middle Name:M
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MS,BOARD CERTIFIED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MACKWORTH ISLAND
Mailing Address - Street 2:STATEWIDE EDUCATIONAL SERVICES MECDHH
Mailing Address - City:FALMOUTH
Mailing Address - State:ME
Mailing Address - Zip Code:04105-1900
Mailing Address - Country:US
Mailing Address - Phone:207-781-6204
Mailing Address - Fax:207-781-6220
Practice Address - Street 1:1 MACKWORTH IS
Practice Address - Street 2:SES - MECDHH
Practice Address - City:FALMOUTH
Practice Address - State:ME
Practice Address - Zip Code:04105-1900
Practice Address - Country:US
Practice Address - Phone:207-781-6204
Practice Address - Fax:207-781-6220
Is Sole Proprietor?:No
Enumeration Date:2009-05-13
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAP303231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist