Healthcare Provider Details

I. General information

NPI: 1043985427
Provider Name (Legal Business Name): MEREDITH JOAN PETERSON MA/CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2021
Last Update Date: 08/09/2021
Certification Date: 08/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

660 MCQUEEN SMITH RD N STE H
PRATTVILLE AL
36066-7559
US

IV. Provider business mailing address

375 ASHTON PARK
MILLBROOK AL
36054-1854
US

V. Phone/Fax

Practice location:
  • Phone: 334-350-3362
  • Fax:
Mailing address:
  • Phone: 662-435-0817
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number5004
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: