Healthcare Provider Details

I. General information

NPI: 1740772003
Provider Name (Legal Business Name): MEGAN LEIGH PETERSON MA, CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2018
Last Update Date: 06/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 W LAKE ST
MELROSE PARK IL
60160-4039
US

IV. Provider business mailing address

1231 N BOSWORTH AVE APT 2R
CHICAGO IL
60642-3330
US

V. Phone/Fax

Practice location:
  • Phone: 708-681-3000
  • Fax:
Mailing address:
  • Phone: 317-674-5062
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number146.013685
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: