MEDICARE: SALLY 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	LCSW20865	CA

General Provider Information

NPI Number	:	1750838942
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SALLY PETERSON LCSW

Provider Business Mailing Address
First Line	:	3160 CAMINO DEL RIO S
Second Line	:	#304
City	:	SAN DIEGO
State	:	CA
Zip	:	92108-3813
Country	:	US
Telephone Number	:	619-819-0283
Fax Number	:	610-819-0284

Provider Business Practice Location Address
First Line	:	3160 CAMINO DEL RIO S
Second Line	:	#304
City	:	SAN DIEGO
State	:	CA
Zip	:	92108-3813
Country	:	US
Telephone Number	:	619-819-0283
Fax Number	:	610-819-0284

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

Provider Enumeration Date	:	09/06/2016
Last Update Date	:	09/06/2016

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