Provider Demographics
NPI:1366602682
Name:PETERSON, DIANA (MS, CCC-A)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MS, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3099 RIVER RD S
Mailing Address - Street 2:STE 120
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-9754
Mailing Address - Country:US
Mailing Address - Phone:503-485-2581
Mailing Address - Fax:503-485-2564
Practice Address - Street 1:3099 RIVER RD S
Practice Address - Street 2:STE 120
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302
Practice Address - Country:US
Practice Address - Phone:503-485-2581
Practice Address - Fax:503-485-2564
Is Sole Proprietor?:No
Enumeration Date:2008-06-10
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORHAS-P-1002783237700000X
OR22596231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500625779Medicaid
OR500625779Medicaid