Provider Demographics
NPI:1811412810
Name:PETERSON, LAURIE (MED)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121B LEE ST
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3314
Mailing Address - Country:US
Mailing Address - Phone:770-830-8622
Mailing Address - Fax:770-832-9031
Practice Address - Street 1:121B LEE ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3314
Practice Address - Country:US
Practice Address - Phone:770-830-8622
Practice Address - Fax:770-832-9031
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-10
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP009608235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003193324AMedicaid
GA05026948OtherAMERIGROUP