Provider Demographics
NPI:1720205255
Name:PETERSEN, WESTE KADE
Entity Type:Individual
Prefix:
First Name:WESTE
Middle Name:KADE
Last Name:PETERSEN
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 1:1054 MARION ST
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95337-5322
Mailing Address - Country:US
Mailing Address - Phone:209-239-9431
Mailing Address - Fax:
Practice Address - Street 1:3000 AUBURN BLVD
Practice Address - Street 2:STE A
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95821-1831
Practice Address - Country:US
Practice Address - Phone:916-483-2154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52760106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist