MEDICARE: MRS. LAVONCIA REGAN PETERSON LCSW, LCASA

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	0904012942	VA
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	LCAS-22699	NC
3	1041C0700X	Clinical Social Worker	C012196	NC

General Provider Information

NPI Number	:	1093268146
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LAVONCIA REGAN PETERSON LCSW, LCASA

Provider Business Mailing Address
First Line	:	200 VALENCIA DR STE 117
Second Line	:
City	:	JACKSONVILLE
State	:	NC
Zip	:	28546-6312
Country	:	US
Telephone Number	:	910-358-6742
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 VALENCIA DR STE 117
Second Line	:
City	:	JACKSONVILLE
State	:	NC
Zip	:	28546-6312
Country	:	US
Telephone Number	:	910-358-6742
Fax Number	:

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

Provider Enumeration Date	:	07/25/2016
Last Update Date	:	01/02/2026

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