Provider Demographics
NPI:1427264050
Name:ROUSSOS, PETER CHRISTOPHER (MA)
Entity type:Individual
Prefix:MR
First Name:PETER
Middle Name:CHRISTOPHER
Last Name:ROUSSOS
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3525 SUITE A DEL MAR HEIGHTS ROAD
Mailing Address - Street 2:BOX 1840
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-2122
Mailing Address - Country:US
Mailing Address - Phone:858-755-2505
Mailing Address - Fax:
Practice Address - Street 1:4246 CORTE FAVOR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-2181
Practice Address - Country:US
Practice Address - Phone:858-755-2505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC34711106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist