Provider Demographics
NPI:1164065041
Name:PRATER, JOHN EDWARD SR
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:EDWARD
Last Name:PRATER
Suffix:SR
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 1:2435 CIENEGA DR
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:CA
Mailing Address - Zip Code:92346-2295
Mailing Address - Country:US
Mailing Address - Phone:219-221-2459
Mailing Address - Fax:
Practice Address - Street 1:1050 N GAREY AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-3802
Practice Address - Country:US
Practice Address - Phone:909-623-6391
Practice Address - Fax:909-620-9491
Is Sole Proprietor?:No
Enumeration Date:2019-10-23
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175T00000X
CA14576-RAC101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist