Provider Demographics
NPI:1235567678
Name:MARVIN, PETER J
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:J
Last Name:MARVIN
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 1:855 CANYON RD
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-5544
Mailing Address - Country:US
Mailing Address - Phone:530-232-1401
Mailing Address - Fax:
Practice Address - Street 1:900 E MAIN ST
Practice Address - Street 2:SUITE 201
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945
Practice Address - Country:US
Practice Address - Phone:530-264-6033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-22
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA70321106H00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health