Provider Demographics
NPI:1427736164
Name:PETERSON, BRAYDON D (CF, SLP)
Entity type:Individual
Prefix:
First Name:BRAYDON
Middle Name:D
Last Name:PETERSON
Suffix:
Gender:M
Credentials:CF, SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 4TH ST W
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-4951
Mailing Address - Country:US
Mailing Address - Phone:701-456-0002
Mailing Address - Fax:
Practice Address - Street 1:444 4TH ST W
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-4951
Practice Address - Country:US
Practice Address - Phone:701-456-0002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-11
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND2420235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist