1275603342 NPI number — MRS. LACY ANNETTE PETERSON M.S., CCC-SLP

Table of content: MRS. LACY ANNETTE PETERSON M.S., CCC-SLP (NPI 1275603342)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275603342 NPI number — MRS. LACY ANNETTE PETERSON M.S., CCC-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSON
Provider First Name:
LACY
Provider Middle Name:
ANNETTE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.S., CCC-SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SHOEMAKER
Provider Other First Name:
LACY
Provider Other Middle Name:
ANNETTE
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1275603342
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:
7112 S MINGO RD
Provider Second Line Business Mailing Address:
SUITE 108
Provider Business Mailing Address City Name:
TULSA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74133-3201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-250-7093
Provider Business Mailing Address Fax Number:
918-250-9976

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7112 S MINGO RD
Provider Second Line Business Practice Location Address:
SUITE 108
Provider Business Practice Location Address City Name:
TULSA
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74133-3201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-250-7093
Provider Business Practice Location Address Fax Number:
918-250-9976
Provider Enumeration Date:
11/08/2006

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:  3230 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 12096911 . This is a "ASHA ACCOUNT NUMBER" identifier . This identifiers is of the category "OTHER".




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