MEDICARE: ABBIGAIL PEDDIESON MFT-LICENSED INTERN

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	106H00000X	Marriage & Family Therapist	MI0465	NV

General Provider Information

NPI Number	:	1043602071
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ABBIGAIL PEDDIESON MFT-LICENSED INTERN

Provider Business Mailing Address
First Line	:	1052 VALLEY LIGHT AVE
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89011-2651
Country	:	US
Telephone Number	:	702-758-4006
Fax Number	:

Provider Business Practice Location Address
First Line	:	3425 CLIFF SHADOWS PKWY
Second Line	:	150
City	:	LAS VEGAS
State	:	NV
Zip	:	89129-5111
Country	:	US
Telephone Number	:	702-758-4006
Fax Number	:

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

Provider Enumeration Date	:	02/27/2015
Last Update Date	:	02/27/2015

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