MEDICARE: MR. COLIN JAMES PETERS I L.C.S.W.

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	18305	IL
2	1041C0700X	Clinical Social Worker	149.012356	IL

General Provider Information

NPI Number	:	1124211578
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. COLIN JAMES PETERS I L.C.S.W.

Provider Business Mailing Address
First Line	:	2709 N MONTICELLO AVE # 1
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-1131
Country	:	US
Telephone Number	:	773-960-4282
Fax Number	:

Provider Business Practice Location Address
First Line	:	6550 N. TALMAN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60645-5323
Country	:	US
Telephone Number	:	773-960-4282
Fax Number	:

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

Provider Enumeration Date	:	08/20/2007
Last Update Date	:	07/31/2014

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