Provider Demographics
NPI:1891576294
Name:PETERS, KACIE LYNN
Entity Type:Individual
Prefix:
First Name:KACIE
Middle Name:LYNN
Last Name:PETERS
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 1:1139 N SHATTUCK ST APT C
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92867-6313
Mailing Address - Country:US
Mailing Address - Phone:407-399-1390
Mailing Address - Fax:
Practice Address - Street 1:101 S KRAEMER BLVD STE 136
Practice Address - Street 2:
Practice Address - City:PLACENTIA
Practice Address - State:CA
Practice Address - Zip Code:92870-6190
Practice Address - Country:US
Practice Address - Phone:949-273-6503
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-11
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18387235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist