Provider Demographics
NPI:1952441966
Name:PETERS, ROGER DALE (MH CLINICIAN II-MFT)
Entity Type:Individual
Prefix:MR
First Name:ROGER
Middle Name:DALE
Last Name:PETERS
Suffix:
Gender:M
Credentials:MH CLINICIAN II-MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2184 ROTHBURY COURT
Mailing Address - Street 2:
Mailing Address - City:TURLOCK
Mailing Address - State:CA
Mailing Address - Zip Code:95382-2980
Mailing Address - Country:US
Mailing Address - Phone:209-667-4098
Mailing Address - Fax:
Practice Address - Street 1:330 MCHENRY AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-0561
Practice Address - Country:US
Practice Address - Phone:209-577-3595
Practice Address - Fax:209-577-4150
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42865101YM0800X
CAMFC51816106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health