MEDICARE: SUSAN CAROL PETERSON LMHC

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	101YM0800X	Mental Health Counselor	LH60824935	WA

General Provider Information

NPI Number	:	1669966446
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN CAROL PETERSON LMHC

Provider Business Mailing Address
First Line	:	PO BOX 1022
Second Line	:
City	:	WINTHROP
State	:	WA
Zip	:	98862-1022
Country	:	US
Telephone Number	:	509-341-4487
Fax Number	:

Provider Business Practice Location Address
First Line	:	105 NORFOLK RD
Second Line	:
City	:	WINTHROP
State	:	WA
Zip	:	98862-4500
Country	:	US
Telephone Number	:	509-341-4487
Fax Number	:

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

Provider Enumeration Date	:	06/15/2018
Last Update Date	:	06/15/2018

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