MEDICARE: TERESA F PETERSEN LCSW

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	58018	TX

General Provider Information

NPI Number	:	1306357025
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TERESA F PETERSEN LCSW

Provider Business Mailing Address
First Line	:	1940 FOUNTAIN VIEW DR # 1091
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77057-3206
Country	:	US
Telephone Number	:	979-341-3614
Fax Number	:

Provider Business Practice Location Address
First Line	:	1940 FOUNTAIN VIEW DR # 1091
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77057-3206
Country	:	US
Telephone Number	:	979-341-3614
Fax Number	:

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

Provider Enumeration Date	:	10/20/2017
Last Update Date	:	06/16/2020

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