Provider Demographics
NPI:1205470556
Name:PETERSON, CYNTHIA M (SLP)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:M
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 1:4570 S LOREN VON DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-4730
Mailing Address - Country:US
Mailing Address - Phone:801-274-0875
Mailing Address - Fax:
Practice Address - Street 1:76 S 500 E
Practice Address - Street 2:
Practice Address - City:SLC
Practice Address - State:UT
Practice Address - Zip Code:84102-1044
Practice Address - Country:US
Practice Address - Phone:801-210-0700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-30
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist