MEDICARE: MS. BETTY JOYCE PETERSON LCSW

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	38358	TX

General Provider Information

NPI Number	:	1447574025
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. BETTY JOYCE PETERSON LCSW

Provider Business Mailing Address
First Line	:	400 N BEACH ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76111-7010
Country	:	US
Telephone Number	:	817-916-5204
Fax Number	:	817-916-4665

Provider Business Practice Location Address
First Line	:	400 N BEACH ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76111-7010
Country	:	US
Telephone Number	:	817-916-5204
Fax Number	:	817-916-4665

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

Provider Enumeration Date	:	03/25/2010
Last Update Date	:	03/25/2010

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