Provider Demographics
NPI:1700065547
Name:PETERSON, KRISTEN D
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:D
Last Name:PETERSON
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 1:1800 PENN ST
Mailing Address - Street 2:SUITE 12
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-2625
Mailing Address - Country:US
Mailing Address - Phone:321-768-6800
Mailing Address - Fax:321-768-6858
Practice Address - Street 1:1800 PENN ST
Practice Address - Street 2:SUITE 12
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2625
Practice Address - Country:US
Practice Address - Phone:321-768-6800
Practice Address - Fax:321-768-6858
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-29
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ4385235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist