Provider Demographics
NPI:1740502160
Name:PETERS, KENNETH DARRYL SR
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:DARRYL
Last Name:PETERS
Suffix:SR
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 1:2911 SLEEPY HOLLOW DR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95209-1144
Mailing Address - Country:US
Mailing Address - Phone:209-475-0199
Mailing Address - Fax:916-327-6017
Practice Address - Street 1:2911 SLEEPY HOLLOW DR
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95209-1144
Practice Address - Country:US
Practice Address - Phone:209-475-0199
Practice Address - Fax:916-327-6017
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-26
Last Update Date:2010-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical