Provider Demographics
NPI:1215112933
Name:PETERSON, NANCY JO (MS CCC SLP)
Entity type:Individual
Prefix:MS
First Name:NANCY
Middle Name:JO
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:MS
Other - First Name:NANCY
Other - Middle Name:JO
Other - Last Name:ASPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC SLP
Mailing Address - Street 1:4635 WAVILLE RD NE
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-8983
Mailing Address - Country:US
Mailing Address - Phone:218-751-2588
Mailing Address - Fax:
Practice Address - Street 1:4635 WAVILLE RD NE
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-8983
Practice Address - Country:US
Practice Address - Phone:218-751-2588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-31
Last Update Date:2007-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7693235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist