Provider Demographics
NPI:1619095825
Name:BALDERAS, PETER ANTHONY (MFT)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:ANTHONY
Last Name:BALDERAS
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 W SUNSET BLVD
Mailing Address - Street 2:ROM 408
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-5861
Mailing Address - Country:US
Mailing Address - Phone:323-361-7703
Mailing Address - Fax:323-361-4779
Practice Address - Street 1:5000 W SUNSET BLVD
Practice Address - Street 2:ROM 408
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-5861
Practice Address - Country:US
Practice Address - Phone:323-361-7703
Practice Address - Fax:323-361-4779
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC37765106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist