MEDICARE: LISA JANE TODD PETERSEN

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	106H00000X	Marriage & Family Therapist	103755	CA

General Provider Information

NPI Number	:	1013422906
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA JANE TODD PETERSEN

Provider Business Mailing Address
First Line	:	1417 MANHATTAN BEACH BLVD
Second Line	:
City	:	MANHATTAN BEACH
State	:	CA
Zip	:	90266-6116
Country	:	US
Telephone Number	:	310-429-6372
Fax Number	:

Provider Business Practice Location Address
First Line	:	515 N SEPULVEDA BLVD
Second Line	:
City	:	MANHATTAN BEACH
State	:	CA
Zip	:	90266-6748
Country	:	US
Telephone Number	:	310-429-6372
Fax Number	:

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

Provider Enumeration Date	:	12/13/2017
Last Update Date	:	12/13/2017

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Directions to “ LISA JANE TODD PETERSEN ” Practice Location

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