Provider Demographics
NPI:1720208705
Name:KOLESNIK, PETER E (PSYD CLINICL PSYCHOL)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:E
Last Name:KOLESNIK
Suffix:
Gender:M
Credentials:PSYD CLINICL PSYCHOL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5106 VIA EL SERENO
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-6250
Mailing Address - Country:US
Mailing Address - Phone:310-378-8870
Mailing Address - Fax:310-378-0200
Practice Address - Street 1:5106 VIA EL SERENO
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-6250
Practice Address - Country:US
Practice Address - Phone:310-378-8870
Practice Address - Fax:310-378-0200
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY17933103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP17933Medicaid
PSY17933OtherCALIF LICENSE
CACP17933Medicare ID - Type Unspecified