Provider Demographics
NPI:1649552654
Name:MCPETERS, KENNETH RAY
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:RAY
Last Name:MCPETERS
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 1:10420 ALMANOR CIR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-7101
Mailing Address - Country:US
Mailing Address - Phone:209-609-6770
Mailing Address - Fax:209-476-8626
Practice Address - Street 1:8900 THORNTON RD STE 6
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95209-1820
Practice Address - Country:US
Practice Address - Phone:209-609-6770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-15
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48999106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist