Provider Demographics
NPI:1508484312
Name:SERRA, PETE
Entity Type:Individual
Prefix:
First Name:PETE
Middle Name:
Last Name:SERRA
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 1:12634 W KEMPSHIRE CT
Mailing Address - Street 2:
Mailing Address - City:STAR
Mailing Address - State:ID
Mailing Address - Zip Code:83669-5145
Mailing Address - Country:US
Mailing Address - Phone:208-447-9967
Mailing Address - Fax:
Practice Address - Street 1:1031 W SANETTA ST
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-5047
Practice Address - Country:US
Practice Address - Phone:208-466-7443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-08
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health