Provider Demographics
NPI:1265607790
Name:PETERSON, ERICA TULLOS (CCC-SLP)
Entity type:Individual
Prefix:MISS
First Name:ERICA
Middle Name:TULLOS
Last Name:PETERSON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:ERICA
Other - Middle Name:
Other - Last Name:TULLOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:921 W BEACON STREET
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:MS
Mailing Address - Zip Code:39350
Mailing Address - Country:US
Mailing Address - Phone:601-650-0002
Mailing Address - Fax:601-650-9902
Practice Address - Street 1:322 HIGHWAY 80 E
Practice Address - Street 2:SUITES 10 & 11
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056
Practice Address - Country:US
Practice Address - Phone:601-460-0910
Practice Address - Fax:601-460-0911
Is Sole Proprietor?:No
Enumeration Date:2008-04-25
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS3095235Z00000X
MSS-3095235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist