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NPI Code Detail

MEDICARE: KALLIE PETERSON

MEDICARE: KALLIE 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
1235Z00000XSpeech-Language Pathologist14336560CO

General Provider Information

NPI Number : 1891368395
Entity Type Code : Individual
Provider Name (Legal Business Name) : KALLIE PETERSON
Provider Business Mailing Address
First Line : 1660 HIGHWAY 100 S STE 103
Second Line :
City : SAINT LOUIS PARK
State : MN
Zip : 55416-1599
Country : US
Telephone Number : 763-531-5039
Fax Number :
Provider Business Practice Location Address
First Line : 9751 REGENT AVE N
Second Line :
City : BROOKLYN PARK
State : MN
Zip : 55443-1402
Country : US
Telephone Number : 763-315-5340
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/21/2021
Last Update Date : 09/25/2024

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Directions to “ KALLIE PETERSON ” Practice Location

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