Provider Demographics
NPI:1124330626
Name:PEDERSON, KAEJAN T (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:KAEJAN
Middle Name:T
Last Name:PEDERSON
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 1:320 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:CORNELL
Mailing Address - State:WI
Mailing Address - Zip Code:54732-8120
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:320 N 7TH ST
Practice Address - Street 2:
Practice Address - City:CORNELL
Practice Address - State:WI
Practice Address - Zip Code:54732-8120
Practice Address - Country:US
Practice Address - Phone:715-239-0440
Practice Address - Fax:715-239-6608
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-13
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3382-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist