Provider Demographics
NPI:1427102128
Name:PEDERSEN, ELIZABETH (SLP)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4707 STAGECOACH CT
Mailing Address - Street 2:
Mailing Address - City:MOORPARK
Mailing Address - State:CA
Mailing Address - Zip Code:93021-3522
Mailing Address - Country:US
Mailing Address - Phone:805-523-8108
Mailing Address - Fax:805-523-8108
Practice Address - Street 1:4707 STAGECOACH CT
Practice Address - Street 2:
Practice Address - City:MOORPARK
Practice Address - State:CA
Practice Address - Zip Code:93021-3522
Practice Address - Country:US
Practice Address - Phone:805-523-8108
Practice Address - Fax:805-523-8108
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP 7184235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist