Basic Information
| Provider Information | |||||||||
| NPI: | 1366564098 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | LORI | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 29 PETER LANE | ||||||||
| Address2: | |||||||||
| City: | KANE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 16735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8147785966 | ||||||||
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| Practice Location | |||||||||
| Address1: | 110 CAMPUS DRIVE | ||||||||
| Address2: | |||||||||
| City: | BRADFORD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 16701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8148875591 | ||||||||
| FaxNumber: | 8148875666 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SL006305L | PA | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 1011532860001 | 05 | PA | MEDICAID |