MEDICARE: LEOLA A PETERSON

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	106	CO

General Provider Information

NPI Number	:	1366465551
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEOLA A PETERSON

Provider Business Mailing Address
First Line	:	95 W BOULDER ST
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80903-3371
Country	:	US
Telephone Number	:	719-339-8010
Fax Number	:	719-272-6464

Provider Business Practice Location Address
First Line	:	95 W BOULDER ST
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80903-2805
Country	:	US
Telephone Number	:	719-339-8010
Fax Number	:	719-272-6464

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

Provider Enumeration Date	:	07/26/2006
Last Update Date	:	07/08/2007

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Directions to “ LEOLA A PETERSON ” Practice Location

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