Provider Demographics
NPI:1366882938
Name:PETERSON, NICOLE YVETTE (BS)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:YVETTE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:278 MARTY DR
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336-3450
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:278 MARTY DR
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-3450
Practice Address - Country:US
Practice Address - Phone:510-377-3455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-27
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst