Individual
MARISSA PETERSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
MA/CCC-SLP
Contact information
Practice address
545 LINCOLN DR, IDAHO FALLS, ID 83401-4118
(208) 757-8553
Mailing address
PO BOX 2943, IDAHO FALLS, ID 83403-2943
(208) 757-8553
(208) 524-1929
Taxonomy
Speciality
Code
Description
License number
State
235Z00000X
Speech-Language Pathologist
Primary
SLP-1685
ID
Other
Enumeration date
06/23/2008
Last updated
07/12/2009
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