MEDICARE: PAUL J PETERSON SOCAIL WORK

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	00130-C	NV

General Provider Information

NPI Number	:	1275646465
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAUL J PETERSON SOCAIL WORK

Provider Business Mailing Address
First Line	:	102 SOUTHEND DR
Second Line	:
City	:	DAYTON
State	:	NV
Zip	:	89403-7414
Country	:	US
Telephone Number	:	775-328-1298
Fax Number	:

Provider Business Practice Location Address
First Line	:	102 SOUTHEND DR
Second Line	:
City	:	DAYTON
State	:	NV
Zip	:	89403-7414
Country	:	US
Telephone Number	:	775-328-1298
Fax Number	:

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

Provider Enumeration Date	:	08/15/2006
Last Update Date	:	07/08/2007

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