Provider Demographics
NPI:1699668905
Name:PETERS, BAILEY RENEE (LAC)
Entity type:Individual
Prefix:
First Name:BAILEY
Middle Name:RENEE
Last Name:PETERS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17235 N 75TH AVE STE E160
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-0829
Mailing Address - Country:US
Mailing Address - Phone:623-738-5210
Mailing Address - Fax:
Practice Address - Street 1:17235 N 75TH AVE STE E160
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-0829
Practice Address - Country:US
Practice Address - Phone:623-738-5210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-03
Last Update Date:2025-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-23530101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health