Healthcare Provider Details

I. General information

NPI: 1053689786
Provider Name (Legal Business Name): ANTON PETRENKO PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2011
Last Update Date: 12/28/2022
Certification Date: 12/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 W LA VETA AVE
ORANGE CA
92868-4203
US

IV. Provider business mailing address

1201 W LA VETA AVE
ORANGE CA
92868-4203
US

V. Phone/Fax

Practice location:
  • Phone: 714-509-3792
  • Fax: 855-246-2329
Mailing address:
  • Phone: 714-509-3792
  • Fax: 855-246-2329

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY33579
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: