MEDICARE: CORTINA DERAL PETERS LMHC

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	IMH7942	FL
2	101YM0800X	Mental Health Counselor	MH11172	FL

General Provider Information

NPI Number	:	1285925578
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CORTINA DERAL PETERS LMHC

Provider Business Mailing Address
First Line	:	1011 AVENUE F
Second Line	:
City	:	RIVIERA BEACH
State	:	FL
Zip	:	33404-7529
Country	:	US
Telephone Number	:	561-315-5939
Fax Number	:

Provider Business Practice Location Address
First Line	:	3600 BROADWAY # US1
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33407-4844
Country	:	US
Telephone Number	:	561-228-8994
Fax Number	:

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

Provider Enumeration Date	:	04/21/2011
Last Update Date	:	03/12/2012

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