Provider Demographics
NPI:1992956379
Name:PETERSON, CANDICE DIANE
Entity type:Individual
Prefix:
First Name:CANDICE
Middle Name:DIANE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1972 MAYBELLE DR
Mailing Address - Street 2:
Mailing Address - City:PLEASANT HILL
Mailing Address - State:CA
Mailing Address - Zip Code:94523-2708
Mailing Address - Country:US
Mailing Address - Phone:925-798-7191
Mailing Address - Fax:
Practice Address - Street 1:902 TUOLUMNE ST
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94590-4641
Practice Address - Country:US
Practice Address - Phone:707-648-8121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-03
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health