Provider Demographics
NPI:1831316397
Name:PETERSON, PATRICIA L
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:L
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CAMPUS DR
Mailing Address - Street 2:
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385-3415
Mailing Address - Country:US
Mailing Address - Phone:636-327-3800
Mailing Address - Fax:636-327-8611
Practice Address - Street 1:600 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-3433
Practice Address - Country:US
Practice Address - Phone:636-327-3876
Practice Address - Fax:636-327-3953
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0385386235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist