Provider Demographics
NPI:1982072849
Name:PETERS, KENNETH MICHAEL (MA, SLP)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:MICHAEL
Last Name:PETERS
Suffix:
Gender:M
Credentials:MA, SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:790 NW 107TH AVE STE 209
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33172-3158
Mailing Address - Country:US
Mailing Address - Phone:786-512-4793
Mailing Address - Fax:786-441-4413
Practice Address - Street 1:790 NW 107TH AVE STE 209
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33172-3158
Practice Address - Country:US
Practice Address - Phone:786-512-4793
Practice Address - Fax:786-441-4413
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-09
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA6156235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist