Provider Demographics
NPI:1851948566
Name:PETERSON, HAYLEY ROSE (CCC SLP)
Entity Type:Individual
Prefix:
First Name:HAYLEY
Middle Name:ROSE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:CCC SLP
Other - Prefix:MS
Other - First Name:HAYLEY
Other - Middle Name:ROSE
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:3027 S NEW HAVEN AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74114-6131
Mailing Address - Country:US
Mailing Address - Phone:918-746-8763
Mailing Address - Fax:
Practice Address - Street 1:3027 S NEW HAVEN AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74114-6131
Practice Address - Country:US
Practice Address - Phone:918-746-8763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-19
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5173235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK5173OtherSTATE LICENSE