Provider Demographics
NPI:1588497309
Name:PETERSON, LINDA (MA, CCC)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MA, CCC
Other - Prefix:
Other - First Name:LINDA
Other - Middle Name:
Other - Last Name:HEBENSTREIT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:302 W GRAND AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-5108
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:302 W GRAND AVE STE 3
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-5108
Practice Address - Country:US
Practice Address - Phone:310-640-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-26
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP5846235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist