MEDICARE: LAUREN 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	101Y00000X	Counselor

General Provider Information

NPI Number	:	1568082345
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAUREN PETERSON

Provider Business Mailing Address
First Line	:	4030 4TH STREET A
Second Line	:
City	:	EAST MOLINE
State	:	IL
Zip	:	61244-3442
Country	:	US
Telephone Number	:	262-332-1343
Fax Number	:

Provider Business Practice Location Address
First Line	:	4030 4TH STREET A
Second Line	:
City	:	EAST MOLINE
State	:	IL
Zip	:	61244-3442
Country	:	US
Telephone Number	:	262-332-1343
Fax Number	:

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

Provider Enumeration Date	:	04/21/2020
Last Update Date	:	04/21/2020

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Directions to “ LAUREN PETERSON ” Practice Location

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