Provider Demographics
NPI:1144432360
Name:PETERSON, SARA MARIE (SLP)
Entity type:Individual
Prefix:MRS
First Name:SARA
Middle Name:MARIE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1209 W TOKAY ST
Mailing Address - Street 2:SUITE 8
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-3845
Mailing Address - Country:US
Mailing Address - Phone:209-334-0830
Mailing Address - Fax:
Practice Address - Street 1:1209 W TOKAY ST
Practice Address - Street 2:SUITE 8
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-3845
Practice Address - Country:US
Practice Address - Phone:209-334-0830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15003235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist