MEDICARE: SALLY A PETERS CSW

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	061437-1	NY

General Provider Information

NPI Number	:	1235131566
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SALLY A PETERS CSW

Provider Business Mailing Address
First Line	:	3405 FONTANA LAKE DR
Second Line	:
City	:	FUQUAY VARINA
State	:	NC
Zip	:	27526-0109
Country	:	US
Telephone Number	:	631-793-2846
Fax Number	:

Provider Business Practice Location Address
First Line	:	3405 FONTANA LAKE DR
Second Line	:
City	:	FUQUAY VARINA
State	:	NC
Zip	:	27526-0109
Country	:	US
Telephone Number	:	631-793-2846
Fax Number	:

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

Provider Enumeration Date	:	05/31/2005
Last Update Date	:	12/18/2019

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