Basic Information
Provider Information | |||||||||
NPI: | 1801234059 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PEAY | ||||||||
FirstName: | TODD | ||||||||
MiddleName: | JULIAN | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PEAY | ||||||||
OtherFirstName: | TODD | ||||||||
OtherMiddleName: | JULIAN | ||||||||
OtherNamePrefix: | MR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | BA | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 3625 14TH ST | ||||||||
Address2: |   | ||||||||
City: | RIVERSIDE | ||||||||
State: | CA | ||||||||
PostalCode: | 925013815 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9519551540 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1500 S HAVEN AVE STE 250 | ||||||||
Address2: |   | ||||||||
City: | ONTARIO | ||||||||
State: | CA | ||||||||
PostalCode: | 917612973 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3235797447 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/10/2013 | ||||||||
LastUpdateDate: | 08/30/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/30/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X |   |   | N |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 106S00000X |   |   | N |   |   |   |   | 171M00000X |   |   | Y |   | Other Service Providers | Case Manager/Care Coordinator |   |
No ID Information.