Provider Demographics
NPI:1205047057
Name:PETERSON, LANCE TAYLOR (LISW)
Entity type:Individual
Prefix:MR
First Name:LANCE
Middle Name:TAYLOR
Last Name:PETERSON
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1551 COMMODORE RD
Mailing Address - Street 2:
Mailing Address - City:LYNDHURST
Mailing Address - State:OH
Mailing Address - Zip Code:44124-2825
Mailing Address - Country:US
Mailing Address - Phone:216-544-4407
Mailing Address - Fax:
Practice Address - Street 1:1551 COMMODORE RD
Practice Address - Street 2:
Practice Address - City:LYNDHURST
Practice Address - State:OH
Practice Address - Zip Code:44124-2825
Practice Address - Country:US
Practice Address - Phone:216-544-4407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
I 06000421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical