Provider Demographics
NPI:1093187890
Name:PETERSON, SYLVESTER RAKEEM
Entity Type:Individual
Prefix:MR
First Name:SYLVESTER
Middle Name:RAKEEM
Last Name:PETERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1435 NE 12TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73117-2012
Mailing Address - Country:US
Mailing Address - Phone:405-800-6569
Mailing Address - Fax:
Practice Address - Street 1:1435 NE 12TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73117-2012
Practice Address - Country:US
Practice Address - Phone:405-800-6569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-20
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor