Provider Demographics
NPI:1992825590
Name:PETERKIN, TYRONE (RAS)
Entity Type:Individual
Prefix:MR
First Name:TYRONE
Middle Name:
Last Name:PETERKIN
Suffix:
Gender:M
Credentials:RAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2261 ELM ST
Mailing Address - Street 2:NAPA
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94559-3721
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2261 ELM ST
Practice Address - Street 2:NAPA
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94559-3721
Practice Address - Country:US
Practice Address - Phone:707-253-6049
Practice Address - Fax:707-259-8716
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAP0509011605101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP0509011605OtherRAS