MEDICARE: MR. CHAD WALTER PETTIES SR.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	92433	CA

General Provider Information

NPI Number	:	1528398971
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CHAD WALTER PETTIES SR.

Provider Business Mailing Address
First Line	:	3939 THIRTENTH STREET
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92507-4944
Country	:	US
Telephone Number	:	951-488-2938
Fax Number	:

Provider Business Practice Location Address
First Line	:	10551 BELLEGRAVE AVE
Second Line	:
City	:	MIRA LOMA
State	:	CA
Zip	:	91752-1800
Country	:	US
Telephone Number	:	951-488-2938
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/07/2010
Last Update Date	:	09/12/2024

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