Provider Demographics
NPI:1548348246
Name:PETERSON, HEATHER A (MS,CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:A
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MS,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3324 KEENES EDGE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-6660
Mailing Address - Country:US
Mailing Address - Phone:573-442-0925
Mailing Address - Fax:
Practice Address - Street 1:3324 KEENES EDGE DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-6660
Practice Address - Country:US
Practice Address - Phone:573-442-0925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004036769235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO467221602Medicaid