Provider Demographics
NPI:1285898825
Name:PETERSON, KIMBERLY ANNE (MA CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ANNE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 N 85TH ST
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4603
Mailing Address - Country:US
Mailing Address - Phone:414-469-8100
Mailing Address - Fax:
Practice Address - Street 1:205 N 85TH ST
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-4603
Practice Address - Country:US
Practice Address - Phone:414-469-8100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-14
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist