Healthcare Provider Details

I. General information

NPI: 1770802696
Provider Name (Legal Business Name): MICHAEL D PETERS PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2010
Last Update Date: 05/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5814 LA SALLE AVE
OAKLAND CA
94611-3210
US

IV. Provider business mailing address

5814 LA SALLE AVE
OAKLAND CA
94611-3210
US

V. Phone/Fax

Practice location:
  • Phone: 510-917-0092
  • Fax:
Mailing address:
  • Phone: 510-917-0092
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: