Provider Demographics
NPI:1760511588
Name:PETERSON, DEENA G (SLP)
Entity Type:Individual
Prefix:MRS
First Name:DEENA
Middle Name:G
Last Name:PETERSON
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 1:1600 MONTANA AVE
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79902-5622
Mailing Address - Country:US
Mailing Address - Phone:915-887-3410
Mailing Address - Fax:915-592-7168
Practice Address - Street 1:1477 LOMALAND DR STE E7
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79935-4704
Practice Address - Country:US
Practice Address - Phone:915-599-6690
Practice Address - Fax:915-592-7168
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2009-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX102699235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX174121701Medicare ID - Type UnspecifiedTPI