MEDICARE: CHANDRA NICOLE PETERSON 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	55071	TX

General Provider Information

NPI Number	:	1508489410
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHANDRA NICOLE PETERSON LCSW

Provider Business Mailing Address
First Line	:	6363 DE ZAVALA RD STE 300
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78249-2104
Country	:	US
Telephone Number	:	210-399-4838
Fax Number	:

Provider Business Practice Location Address
First Line	:	6363 DE ZAVALA RD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78249-2103
Country	:	US
Telephone Number	:	210-399-4838
Fax Number	:

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

Provider Enumeration Date	:	05/26/2020
Last Update Date	:	05/26/2020

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