Provider Demographics
NPI:1821129883
Name:RAYMOND, PETER JEROME
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:JEROME
Last Name:RAYMOND
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 1:13951 LEMOLI AVE
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-8851
Mailing Address - Country:US
Mailing Address - Phone:310-347-2425
Mailing Address - Fax:
Practice Address - Street 1:13951 LEMOLI AVE
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-8851
Practice Address - Country:US
Practice Address - Phone:310-347-2425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2013-05-07
Deactivation Date:2007-07-27
Deactivation Code:
Reactivation Date:2007-08-15
Provider Licenses
StateLicense IDTaxonomies
CARI-R0702161638101YA0400X
225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)