Provider Demographics
NPI:1740675867
Name:PETERS, PHILLIP E (BCBA)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:E
Last Name:PETERS
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4566 PESCADERO AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92107-3537
Mailing Address - Country:US
Mailing Address - Phone:310-961-0381
Mailing Address - Fax:
Practice Address - Street 1:1550 HOTEL CIR N
Practice Address - Street 2:SUITE#450
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-2901
Practice Address - Country:US
Practice Address - Phone:619-692-1581
Practice Address - Fax:619-692-1588
Is Sole Proprietor?:No
Enumeration Date:2015-04-06
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0-15-6538103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW416OtherMEDICARE #