Provider Demographics
NPI:1053902254
Name:PETEN, TERRESHA Y
Entity type:Individual
Prefix:MISS
First Name:TERRESHA
Middle Name:Y
Last Name:PETEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4915 W LYNNE LN
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-4240
Mailing Address - Country:US
Mailing Address - Phone:779-248-1040
Mailing Address - Fax:
Practice Address - Street 1:2444 W BLOCH RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85041-2930
Practice Address - Country:US
Practice Address - Phone:779-248-1040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-30
Last Update Date:2021-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health