Provider Demographics
NPI:1154447191
Name:RADESTOCK, PETER JOHN (PHD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:JOHN
Last Name:RADESTOCK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:87 N RAYMOND AVE
Mailing Address - Street 2:#620
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91103-3932
Mailing Address - Country:US
Mailing Address - Phone:626-585-8440
Mailing Address - Fax:626-793-6949
Practice Address - Street 1:87 N RAYMOND AVE
Practice Address - Street 2:#620
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91103-3932
Practice Address - Country:US
Practice Address - Phone:626-585-8440
Practice Address - Fax:626-793-6949
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 23526106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist