MEDICARE: ELIZABETH ANN PETERSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	7210	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	4600318	OTHER		MEDICA

General Provider Information

NPI Number	:	1184640260
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH ANN PETERSON

Provider Business Mailing Address
First Line	:	530 E 2ND ST
Second Line	:
City	:	DULUTH
State	:	MN
Zip	:	55805-1913
Country	:	US
Telephone Number	:	218-786-5360
Fax Number	:

Provider Business Practice Location Address
First Line	:	1600 MILLER TRUNK HWY STE 1300
Second Line	:
City	:	DULUTH
State	:	MN
Zip	:	55811-5640
Country	:	US
Telephone Number	:	218-786-3392
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/14/2006
Last Update Date	:	01/29/2025

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Directions to “ ELIZABETH ANN PETERSON ” Practice Location

Language	Start Address	Practice Location

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