MEDICARE: MR. KENT G. PETERSON 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	MH 00547	FL

General Provider Information

NPI Number	:	1316049539
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KENT G. PETERSON LMHC

Provider Business Mailing Address
First Line	:	13031 LEXINGTON SUMMIT ST
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32828-4309
Country	:	US
Telephone Number	:	407-883-9900
Fax Number	:

Provider Business Practice Location Address
First Line	:	1817 CRESCENT BLVD STE 101D
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32817-4619
Country	:	US
Telephone Number	:	407-883-9900
Fax Number	:

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

Provider Enumeration Date	:	09/01/2006
Last Update Date	:	04/02/2021

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