Provider Demographics
NPI:1851537849
Name:PETERSON, KRISTIN (SLP)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
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 1:1733 W IRVING PARK RD APT 321
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-2561
Mailing Address - Country:US
Mailing Address - Phone:773-983-2118
Mailing Address - Fax:
Practice Address - Street 1:1733 W IRVING PARK RD APT 321
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-2561
Practice Address - Country:US
Practice Address - Phone:773-983-2118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-23
Last Update Date:2008-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146005279235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist