Provider Demographics
NPI:1790927713
Name:PETERSON, STEPHANIE (MA)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1994 E RUM RIVER DR S
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MN
Mailing Address - Zip Code:55008-2663
Mailing Address - Country:US
Mailing Address - Phone:763-689-5385
Mailing Address - Fax:763-689-5558
Practice Address - Street 1:1994 E RUM RIVER DR S
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MN
Practice Address - Zip Code:55008-2663
Practice Address - Country:US
Practice Address - Phone:763-689-5385
Practice Address - Fax:763-689-5558
Is Sole Proprietor?:No
Enumeration Date:2009-04-06
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9835235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist