Provider Demographics
NPI:1134249246
Name:PETERSEN, THOMAS DAVID (MSCCCSLP)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:DAVID
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:MSCCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N4901 DAM RD
Mailing Address - Street 2:
Mailing Address - City:DELAVAN
Mailing Address - State:WI
Mailing Address - Zip Code:53115-2927
Mailing Address - Country:US
Mailing Address - Phone:262-740-2170
Mailing Address - Fax:262-740-7201
Practice Address - Street 1:N4901 DAM RD
Practice Address - Street 2:
Practice Address - City:DELAVAN
Practice Address - State:WI
Practice Address - Zip Code:53115-2927
Practice Address - Country:US
Practice Address - Phone:262-740-2170
Practice Address - Fax:262-740-7201
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2444154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist