MEDICARE: MR. MICHAEL 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	LCS 20727	CA

General Provider Information

NPI Number	:	1750651113
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MICHAEL PETERSON LCSW

Provider Business Mailing Address
First Line	:	1400 N HAYWORTH AVE APT 9
Second Line	:
City	:	WEST HOLLYWOOD
State	:	CA
Zip	:	90046-3836
Country	:	US
Telephone Number	:	310-498-2632
Fax Number	:

Provider Business Practice Location Address
First Line	:	1400 N HAYWORTH AVE APT 9
Second Line	:
City	:	WEST HOLLYWOOD
State	:	CA
Zip	:	90046-3836
Country	:	US
Telephone Number	:	310-498-2632
Fax Number	:

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

Provider Enumeration Date	:	01/03/2012
Last Update Date	:	01/03/2012

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