Provider Demographics
NPI:1245522911
Name:PETERS, ELIZABETH (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:PETERS
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:BETTS
Other - Middle Name:
Other - Last Name:PETERS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA, CCC-SLP
Mailing Address - Street 1:4016 SE 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-3920
Mailing Address - Country:US
Mailing Address - Phone:503-309-8239
Mailing Address - Fax:
Practice Address - Street 1:4016 SE 14TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-3920
Practice Address - Country:US
Practice Address - Phone:503-309-8239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-12
Last Update Date:2012-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13167235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
12130464OtherAMERICAN SPEECH, LANGUAGE & HEARING ASSOCIATION (ASHA)
OR13167OtherOREGON BOARD OF EXAMINERS FOR SPEECH-LANGUAGE PATHOLOGY AND AUDIOLOGY