Provider Demographics
NPI:1366564098
Name:PETERSON, LORI ANN
Entity type:Individual
Prefix:MRS
First Name:LORI
Middle Name:ANN
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 1:29 PETER LANE
Mailing Address - Street 2:
Mailing Address - City:KANE
Mailing Address - State:PA
Mailing Address - Zip Code:16735
Mailing Address - Country:US
Mailing Address - Phone:814-778-5966
Mailing Address - Fax:
Practice Address - Street 1:110 CAMPUS DRIVE
Practice Address - Street 2:
Practice Address - City:BRADFORD
Practice Address - State:PA
Practice Address - Zip Code:16701
Practice Address - Country:US
Practice Address - Phone:814-887-5591
Practice Address - Fax:814-887-5666
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL006305L235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1011532860001Medicaid