MEDICARE: MICHAEL LATRAE 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	104100000X	Social Worker	1703509043	NV

General Provider Information

NPI Number	:	1548715634
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL LATRAE PETERSON

Provider Business Mailing Address
First Line	:	6767 W WINDMILL LN
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89139-6501
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6767 W WINDMILL LN
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89139-6501
Country	:	US
Telephone Number	:	702-578-0608
Fax Number	:

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

Provider Enumeration Date	:	08/18/2016
Last Update Date	:	08/18/2016

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Directions to “ MICHAEL LATRAE PETERSON ” Practice Location

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