1598147753 NPI number — KACIE WEBB PETERSON MA, CCC-L/SLP

Table of content: KACIE WEBB PETERSON MA, CCC-L/SLP (NPI 1598147753)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598147753 NPI number — KACIE WEBB PETERSON MA, CCC-L/SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSON
Provider First Name:
KACIE
Provider Middle Name:
WEBB
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA, CCC-L/SLP
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:
1598147753
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3990 N BLUE SAGE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE CHARLES
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70605-0189
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-802-0473
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
852 UNIVERSITY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE CHARLES
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70605-6120
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-419-0086
Provider Business Practice Location Address Fax Number:
337-415-0626
Provider Enumeration Date:
06/24/2015

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:  7374 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2450662 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com