Basic Information
| Provider Information | |||||||||
| NPI: | 1265911721 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSEN | ||||||||
| FirstName: | EUGENIA | ||||||||
| MiddleName: | KAY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4560 SE INTERNATIONAL WAY STE 100 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKIE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972224628 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 20 VILLAGE CIRCLE, KEOKUK IOWA | ||||||||
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| City: | KEOKUK | ||||||||
| State: | IA | ||||||||
| PostalCode: | 52632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3195245772 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2018 | ||||||||
| LastUpdateDate: | 08/07/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 00693 | IA | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.