Healthcare Provider Details

I. General information

NPI: 1538202635
Provider Name (Legal Business Name): MR. TOM FERENCZIK PETERS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 05/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 MCHENRY VILLAGE WAY # 11
MODESTO CA
95350-4308
US

IV. Provider business mailing address

1053 E 6 TH STREET
ONTARIO CA
91764-0000
US

V. Phone/Fax

Practice location:
  • Phone: 209-526-1476
  • Fax: 209-526-0908
Mailing address:
  • Phone: 909-284-0423
  • Fax: 909-284-0423

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number49290
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: