MEDICARE: MS. LESLIE PETERSON MSW

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

General Provider Information

NPI Number	:	1942404363
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LESLIE PETERSON MSW

Provider Business Mailing Address
First Line	:	4007 COSMO ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92111-3419
Country	:	US
Telephone Number	:	760-967-7082
Fax Number	:	760-967-1465

Provider Business Practice Location Address
First Line	:	3142 VISTA WAY STE 207
Second Line	:
City	:	OCEANSIDE
State	:	CA
Zip	:	92056-3628
Country	:	US
Telephone Number	:	760-967-7082
Fax Number	:	760-967-1465

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

Provider Enumeration Date	:	06/11/2007
Last Update Date	:	07/08/2007

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