Provider Demographics
NPI:1871115139
Name:PETERSEN, LINDSAY RAE
Entity type:Individual
Prefix:
First Name:LINDSAY
Middle Name:RAE
Last Name:PETERSEN
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 1:439 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SENECA
Mailing Address - State:IL
Mailing Address - Zip Code:61360-9437
Mailing Address - Country:US
Mailing Address - Phone:815-674-9997
Mailing Address - Fax:
Practice Address - Street 1:9500 JOLIET RD
Practice Address - Street 2:
Practice Address - City:HODGKINS
Practice Address - State:IL
Practice Address - Zip Code:60525-4137
Practice Address - Country:US
Practice Address - Phone:469-503-0112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-09
Last Update Date:2020-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2931237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist