Provider Demographics
NPI:1467644112
Name:PETERSON, JULIE MARIE (AUD, CCC-A CO#829)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:MARIE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:AUD, CCC-A CO#829
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6121 SECREST CT
Mailing Address - Street 2:
Mailing Address - City:ARVADA
Mailing Address - State:CO
Mailing Address - Zip Code:80403-7501
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6121 SECREST CT
Practice Address - Street 2:
Practice Address - City:ARVADA
Practice Address - State:CO
Practice Address - Zip Code:80403-7501
Practice Address - Country:US
Practice Address - Phone:520-425-5766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-16
Last Update Date:2017-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO829231H00000X
AZDA985231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ427569Medicaid
AZ427569Medicaid