MEDICARE: MR. KYLE 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	104100000X	Social Worker	131900-121	WI
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	19344-130	WI
3	1041C0700X	Clinical Social Worker	9983-123	WI

General Provider Information

NPI Number	:	1700466117
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KYLE PETERSON LCSW

Provider Business Mailing Address
First Line	:	4800 N SCOTTSDALE RD STE 2500
Second Line	:
City	:	SCOTTSDALE
State	:	AZ
Zip	:	85251-7630
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	440 SCIENCE DR STE 300
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53711-1064
Country	:	US
Telephone Number	:	262-999-3495
Fax Number	:

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

Provider Enumeration Date	:	04/09/2021
Last Update Date	:	02/18/2026

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Directions to “ MR. KYLE PETERSON LCSW” Practice Location

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