1417147760 NPI number — KEESHA L. PETERSON M. S. CCC-SLP

Table of content: KEESHA L. PETERSON M. S. CCC-SLP (NPI 1417147760)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417147760 NPI number — KEESHA L. PETERSON M. S. CCC-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSON
Provider First Name:
KEESHA
Provider Middle Name:
L.
Provider Name Prefix Text:
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:
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:
1417147760
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/11/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1418 COLLEGE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNT CARMEL
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62863-2638
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-263-6343
Provider Business Mailing Address Fax Number:
618-263-6477

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1418 COLLEGE DRIVE
Provider Second Line Business Practice Location Address:
PHYSICAL MEDICINE DEPARTMENT
Provider Business Practice Location Address City Name:
MOUNT CARMEL
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62863
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-263-6343
Provider Business Practice Location Address Fax Number:
618-263-6477
Provider Enumeration Date:
08/01/2007

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:  22003291A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 235Z00000X , with the licence number: 146-005206 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com