Healthcare Provider Details

I. General information

NPI: 1053222695
Provider Name (Legal Business Name): PETER LEROY LOUNIBOS MA, MS, SLP-CCC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2140 JENNINGS AVE
SANTA ROSA CA
95401-9528
US

IV. Provider business mailing address

1905 KNOLLS DR
SANTA ROSA CA
95405-8322
US

V. Phone/Fax

Practice location:
  • Phone: 707-890-3825
  • Fax:
Mailing address:
  • Phone: 707-364-7503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number20999
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: