Provider Demographics
NPI:1124398987
Name:CUSIMANO, PETER CHARLES (LAADC, MATS, SAP)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:CHARLES
Last Name:CUSIMANO
Suffix:
Gender:M
Credentials:LAADC, MATS, SAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 STANLEY AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95065-1909
Mailing Address - Country:US
Mailing Address - Phone:650-669-1578
Mailing Address - Fax:650-326-1340
Practice Address - Street 1:999 W TAYLOR ST STE B
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95126-1861
Practice Address - Country:US
Practice Address - Phone:650-669-1578
Practice Address - Fax:650-648-1654
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-10
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALR01660815101YA0400X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)