Basic Information
| Provider Information | |||||||||
| NPI: | 1467702860 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERS | ||||||||
| FirstName: | DOREEN | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | RAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 SOUTH BLUFF DRIVE | ||||||||
| Address2: | |||||||||
| City: | ROSEVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95678 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164101126 | ||||||||
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| Practice Location | |||||||||
| Address1: | 180 SIERRA COLLEGE DR | ||||||||
| Address2: | |||||||||
| City: | GRASS VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959455768 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302739541 | ||||||||
| FaxNumber: | 5302737740 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2012 | ||||||||
| LastUpdateDate: | 05/28/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | P0806061611 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | P0806061611 | 01 | CA | RAS | OTHER |