Provider Demographics
NPI:1255109732
Name:PEREDA, LORENA
Entity type:Individual
Prefix:
First Name:LORENA
Middle Name:
Last Name:PEREDA
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 1:4044 MATCH POINT AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95407-2524
Mailing Address - Country:US
Mailing Address - Phone:408-781-1903
Mailing Address - Fax:
Practice Address - Street 1:1301 REDWOOD WAY
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-1107
Practice Address - Country:US
Practice Address - Phone:707-763-6419
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-14
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18782235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist