Basic Information
| Provider Information | |||||||||
| NPI: | 1265607790 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | ERICA | ||||||||
| MiddleName: | TULLOS | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | CCC-SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TULLOS | ||||||||
| OtherFirstName: | ERICA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 921 W BEACON STREET | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6016500002 | ||||||||
| FaxNumber: | 6016509902 | ||||||||
| Practice Location | |||||||||
| Address1: | 322 HIGHWAY 80 E | ||||||||
| Address2: | SUITES 10 & 11 | ||||||||
| City: | CLINTON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6014600910 | ||||||||
| FaxNumber: | 6014600911 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2008 | ||||||||
| LastUpdateDate: | 02/17/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | S3095 | MS | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | S-3095 | MS | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.