Provider Demographics
NPI:1679760599
Name:PETERS, CHRISTIAN AVERY
Entity type:Individual
Prefix:MR
First Name:CHRISTIAN
Middle Name:AVERY
Last Name:PETERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12712 HEACOCK ST
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-3037
Mailing Address - Country:US
Mailing Address - Phone:951-247-6064
Mailing Address - Fax:951-242-6201
Practice Address - Street 1:12712 HEACOCK ST
Practice Address - Street 2:SUITE 9-B
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-3037
Practice Address - Country:US
Practice Address - Phone:951-247-6064
Practice Address - Fax:951-242-6201
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-25
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist