Provider Demographics
NPI:1689280802
Name:PETERSEN, BERKLEY JUNE (AUD)
Entity type:Individual
Prefix:
First Name:BERKLEY
Middle Name:JUNE
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224-D CORNWALL STREET, NW, SUITE 403
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-2704
Mailing Address - Country:US
Mailing Address - Phone:703-737-6010
Mailing Address - Fax:
Practice Address - Street 1:6355 WALKER LANE, SUITE 308
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22310-3247
Practice Address - Country:US
Practice Address - Phone:703-313-7700
Practice Address - Fax:703-313-0178
Is Sole Proprietor?:No
Enumeration Date:2020-09-22
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3532231H00000X
VA2201001869231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA30017888610001Medicaid
VA1689280802Medicaid