Provider Demographics
NPI:1407079205
Name:KRISTIN M. PETERSON LTD
Entity type:Organization
Organization Name:KRISTIN M. PETERSON LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC-SLP
Authorized Official - Phone:773-983-2118
Mailing Address - Street 1:1733 W IRVING PARK RD
Mailing Address - Street 2:# 321
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-2500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1733 W IRVING PARK RD
Practice Address - Street 2:# 321
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-2500
Practice Address - Country:US
Practice Address - Phone:773-983-2118
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146005279235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty