Provider Demographics
NPI:1558615112
Name:PETERS, GERALD J
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:J
Last Name:PETERS
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 1:916 N MOUNTAIN AVE STE A
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-3658
Mailing Address - Country:US
Mailing Address - Phone:909-932-1069
Mailing Address - Fax:
Practice Address - Street 1:44447 10TH ST W
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-3324
Practice Address - Country:US
Practice Address - Phone:661-726-2630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-05
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)