Provider Demographics
NPI:1992052955
Name:PETERSEN, DANIELLE M (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:M
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20402 N 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-3636
Mailing Address - Country:US
Mailing Address - Phone:623-445-4952
Mailing Address - Fax:623-445-5083
Practice Address - Street 1:20402 N 15TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-3636
Practice Address - Country:US
Practice Address - Phone:623-445-4952
Practice Address - Fax:623-445-5083
Is Sole Proprietor?:No
Enumeration Date:2012-08-09
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA77802355S0801X
AZSLP7780235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant