Provider Demographics
NPI:1609083609
Name:BURTIS, PETER K (LMFT)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:K
Last Name:BURTIS
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 653
Mailing Address - Street 2:
Mailing Address - City:MENDOCINO
Mailing Address - State:CA
Mailing Address - Zip Code:95460
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:347 CYPRESS ST STE A
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:CA
Practice Address - Zip Code:95437-5458
Practice Address - Country:US
Practice Address - Phone:707-962-3161
Practice Address - Fax:707-937-1876
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2023-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT39126106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1609083609Medicaid