Provider Demographics
NPI:1558198044
Name:PETERSON, MYKALEE NICHOLE
Entity type:Individual
Prefix:
First Name:MYKALEE
Middle Name:NICHOLE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 SUMMIT CROSSING LN APT 106
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-2206
Mailing Address - Country:US
Mailing Address - Phone:903-804-7124
Mailing Address - Fax:
Practice Address - Street 1:1720 SUMMIT CROSSING LN APT 106
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-2206
Practice Address - Country:US
Practice Address - Phone:903-804-7124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-18
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX123173235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist