Provider Demographics
NPI:1780654731
Name:PETERSEN, FLORENCE (CCC/A)
Entity type:Individual
Prefix:MS
First Name:FLORENCE
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:CCC/A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2211 LOMAS BLVD
Mailing Address - Street 2:5 NORTH, AUDIOLOGY
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87131-0001
Mailing Address - Country:US
Mailing Address - Phone:505-272-9581
Mailing Address - Fax:505-272-3030
Practice Address - Street 1:2211 LOMAS BLVD
Practice Address - Street 2:5 NORTH, AUDIOLOGY
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87131-0001
Practice Address - Country:US
Practice Address - Phone:505-272-9581
Practice Address - Fax:505-272-3030
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2568231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM992289Medicaid