=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144327560
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELIZABETH PETERSON MSW,LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2647 MICHIGAN AVE
-----------------------------------------------------
City | KISSIMMEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34744-1936
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-846-5220
-----------------------------------------------------
Fax | 407-846-5225
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3571 SANCTUARY DRIVE
-----------------------------------------------------
City | SAINT CLOUD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34769
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-498-3056
-----------------------------------------------------
Fax | 407-846-5225
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | SW8281
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------