MEDICARE: MS. DEANNA SUE PETERSEN 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	LCS9190	CA

General Provider Information

NPI Number	:	1679668149
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DEANNA SUE PETERSEN LCSW

Provider Business Mailing Address
First Line	:	1224 10TH STREET
Second Line	:	SUITE 206
City	:	CORONADO
State	:	CA
Zip	:	92118-3420
Country	:	US
Telephone Number	:	619-437-4812
Fax Number	:	619-437-1881

Provider Business Practice Location Address
First Line	:	1224 10TH STREET
Second Line	:	SUITE 206
City	:	CORONADO
State	:	CA
Zip	:	92118-3420
Country	:	US
Telephone Number	:	619-437-4812
Fax Number	:	619-437-1881

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

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	07/08/2007

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