Provider Demographics
NPI:1215332846
Name:PETERSON, CAROLYN (MA-CCC,SLP)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MA-CCC,SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:239 GRANNYS GARDEN RD
Mailing Address - Street 2:
Mailing Address - City:LIBBY
Mailing Address - State:MT
Mailing Address - Zip Code:59923-9218
Mailing Address - Country:US
Mailing Address - Phone:406-293-7480
Mailing Address - Fax:
Practice Address - Street 1:239 GRANNYS GARDEN RD
Practice Address - Street 2:
Practice Address - City:LIBBY
Practice Address - State:MT
Practice Address - Zip Code:59923-9218
Practice Address - Country:US
Practice Address - Phone:406-293-7480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-24
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT746235Z00000X
AZ9140235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist