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General NPI Number Information
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NPI Number | 1083750996
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Entity Type | Individual
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Provider Name | ELIZA S. PETERSEN AUD, CCCA
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Gender | Female
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Dates
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Enumeration Date | 01/29/2007
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Last Update Date | 04/19/2023
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Provider Practice Location Address
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Address Line | 2740 SHADOWMOON LN STE 417
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City | DRIGGS
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State | ID
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Zip | 83422-5083
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Country | US
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Telephone | 307-745-5587
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Fax | 877-515-1633
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Provider Business Mailing Address
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Address Line | 1388 MOUNT MORIAH RD
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City | LIVERMORE
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State | CO
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Zip | 80536-9311
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Country | US
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Telephone | 307-745-5587
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Fax | 877-515-1633
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 231H00000X
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Taxonomy Name | Audiologist
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License Number | A-974
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License Number State | WY
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Taxonomy #2
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Taxonomy Code | 231H00000X
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Taxonomy Name | Audiologist
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License Number | AUD-1142
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License Number State | ID
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