MEDICARE: LAUREN MARIE PETERSEN BCBA

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	103K00000X	Behavior Analyst	0133002566	VA
2	103K00000X	Behavior Analyst	BA-1014	HI

General Provider Information

NPI Number	:	1013648682
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAUREN MARIE PETERSEN BCBA

Provider Business Mailing Address
First Line	:	7007 HAWAII KAI DR APT L12
Second Line	:
City	:	HONOLULU
State	:	HI
Zip	:	96825-4128
Country	:	US
Telephone Number	:	573-760-2488
Fax Number	:

Provider Business Practice Location Address
First Line	:	7007 HAWAII KAI DR APT L12
Second Line	:
City	:	HONOLULU
State	:	HI
Zip	:	96825-4128
Country	:	US
Telephone Number	:	573-760-2488
Fax Number	:

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

Provider Enumeration Date	:	06/23/2022
Last Update Date	:	06/09/2026

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