Provider Demographics
NPI:1801378021
Name:PETERSON, SUSAN NELL (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:NELL
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:LIFESCAPE ABLE KIDS
Mailing Address - Street 2:2524 GLENN AVE
Mailing Address - City:SIOUX CITY
Mailing Address - State:SD
Mailing Address - Zip Code:51106
Mailing Address - Country:US
Mailing Address - Phone:712-226-2253
Mailing Address - Fax:712-226-2254
Practice Address - Street 1:LIFESCAPE ABLE KIDS
Practice Address - Street 2:2524 GLENN AVE.
Practice Address - City:SIOUX CITY
Practice Address - State:SD
Practice Address - Zip Code:51106
Practice Address - Country:US
Practice Address - Phone:712-226-2253
Practice Address - Fax:712-226-2254
Is Sole Proprietor?:No
Enumeration Date:2018-09-04
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA10681235500000X
235Z00000X
SD801-SLP235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No235500000XSpeech, Language and Hearing Service ProvidersSpecialist/Technologist