Healthcare Provider Details

I. General information

NPI: 1720803257
Provider Name (Legal Business Name): RICHARD HERCHEL PETERS JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2024
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4038 MCCLAIN WAY APT 101
CARMICHAEL CA
95608-8100
US

IV. Provider business mailing address

4038 MCCLAIN WAY APT 101
CARMICHAEL CA
95608-8100
US

V. Phone/Fax

Practice location:
  • Phone: 279-204-4133
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCI43830724
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: