Provider Demographics
NPI:1952432767
Name:PETERS-KAMMERAAD, TONYA LYNN (LCSW, NCPSYA)
Entity Type:Individual
Prefix:
First Name:TONYA
Middle Name:LYNN
Last Name:PETERS-KAMMERAAD
Suffix:
Gender:F
Credentials:LCSW, NCPSYA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1835 NEWPORT BLVD
Mailing Address - Street 2:SUITE A109-PMB165
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-5031
Mailing Address - Country:US
Mailing Address - Phone:310-359-8972
Mailing Address - Fax:
Practice Address - Street 1:1835 NEWPORT BLVD
Practice Address - Street 2:SUITE A109-PMB165
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-5031
Practice Address - Country:US
Practice Address - Phone:310-359-8972
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2010-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY070701-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical