1588640304 NPI number — HEATHER ALYSA PETERSON MS SLP LLL

Table of content: HEATHER ALYSA PETERSON MS SLP LLL (NPI 1588640304)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588640304 NPI number — HEATHER ALYSA PETERSON MS SLP LLL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSON
Provider First Name:
HEATHER
Provider Middle Name:
ALYSA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS SLP LLL
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1588640304
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1824 BELMONT RD NW
Provider Second Line Business Mailing Address:
#31
Provider Business Mailing Address City Name:
WASHINGTON
Provider Business Mailing Address State Name:
DC
Provider Business Mailing Address Postal Code:
20009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
202-425-6874
Provider Business Mailing Address Fax Number:
703-922-0638

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6506 LOISDALE RD
Provider Second Line Business Practice Location Address:
SUITE #300
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22150
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-924-4183
Provider Business Practice Location Address Fax Number:
703-922-0638
Provider Enumeration Date:
12/22/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  12074933 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com