Provider Demographics
NPI:1447723077
Name:PETERSON, CAROL L (CCC-SLP)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:L
Last Name:PETERSON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1503 GLASGOW ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21613-1350
Mailing Address - Country:US
Mailing Address - Phone:410-228-7978
Mailing Address - Fax:
Practice Address - Street 1:700 GLASGOW ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21613-1738
Practice Address - Country:US
Practice Address - Phone:410-228-4747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-07
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD05272235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD23Medicaid