MEDICARE: KRISTIN M. PETERSON LTD

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	146005279	IL

General Provider Information

NPI Number	:	1407079205
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KRISTIN M. PETERSON LTD

Provider Business Mailing Address
First Line	:	1733 W IRVING PARK RD
Second Line	:	# 321
City	:	CHICAGO
State	:	IL
Zip	:	60613-2500
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1733 W IRVING PARK RD
Second Line	:	# 321
City	:	CHICAGO
State	:	IL
Zip	:	60613-2500
Country	:	US
Telephone Number	:	773-983-2118
Fax Number	:

Authorized Official
Title or Position	:	SPEECH PATHOLOGIST
Name	:	KRISTIN PETERSON
Credential	:	M.S. CCC-SLP
Telephone Number	:	773-983-2118

Provider Enumeration Date	:	04/10/2007
Last Update Date	:	05/24/2011

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