Individual
LAURIE PETERSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
MED
Contact information
Practice address
121B LEE ST, CARROLLTON, GA 30117-3314
(770) 830-8622
(770) 832-9031
Mailing address
121B LEE ST, CARROLLTON, GA 30117-3314
(770) 830-8622
(770) 832-9031
Taxonomy
Speciality
Code
Description
License number
State
235Z00000X
Speech-Language Pathologist
Primary
SLP009608
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
003193324A
—
GA
01
—
05026948
AMERIGROUP
GA
Enumeration date
08/10/2017
Last updated
03/22/2018
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