MEDICARE: SUSAN K. PETERSON LICSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	LW00006437	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8902748	OTHER	WA	L&I CRIME VICTIMS

General Provider Information

NPI Number	:	1013014349
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN K. PETERSON LICSW

Provider Business Mailing Address
First Line	:	1513 25TH AVE
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98122-3017
Country	:	US
Telephone Number	:	206-328-5010
Fax Number	:

Provider Business Practice Location Address
First Line	:	1513 25TH AVE
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98122-3017
Country	:	US
Telephone Number	:	206-328-5010
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	09/29/2010

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