MEDICARE: MR. CODY CRAIG PETERSON BA

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1174952725
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CODY CRAIG PETERSON BA

Provider Business Mailing Address
First Line	:	2200 W BERRY AVE
Second Line	:
City	:	LITTLETON
State	:	CO
Zip	:	80120-1101
Country	:	US
Telephone Number	:	303-798-0128
Fax Number	:	303-798-9640

Provider Business Practice Location Address
First Line	:	2200 W BERRY AVE
Second Line	:
City	:	LITTLETON
State	:	CO
Zip	:	80120-1101
Country	:	US
Telephone Number	:	303-798-0128
Fax Number	:	303-798-9640

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

Provider Enumeration Date	:	11/04/2013
Last Update Date	:	12/23/2013

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