Provider Demographics
NPI:1053744342
Name:PETERSON, DONNA LEE (MSC SLP)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:LEE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MSC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3466 E LONGHORN DR
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85297-7782
Mailing Address - Country:US
Mailing Address - Phone:480-621-8361
Mailing Address - Fax:
Practice Address - Street 1:3271 E QUEEN CREEK RD
Practice Address - Street 2:SUITE 101
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-8508
Practice Address - Country:US
Practice Address - Phone:480-621-8361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-09
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP8218235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist