MEDICARE: MR. MILTON PETERSON JR. LCDC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	LCDC#696	TX

General Provider Information

NPI Number	:	1700295326
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MILTON PETERSON JR. LCDC

Provider Business Mailing Address
First Line	:	2353 AVENUE M APT 29
Second Line	:
City	:	HUNTSVILLE
State	:	TX
Zip	:	77340-5752
Country	:	US
Telephone Number	:	936-439-5746
Fax Number	:

Provider Business Practice Location Address
First Line	:	5711 LAVENDER ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77026-1725
Country	:	US
Telephone Number	:	713-557-8573
Fax Number	:

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

Provider Enumeration Date	:	08/07/2014
Last Update Date	:	08/07/2014

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