Provider Demographics
NPI:1003795915
Name:PETERSON, PAUL ANTHONY
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:ANTHONY
Last Name:PETERSON
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 1:1274 CENTER COURT DR STE 211
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91724-3668
Mailing Address - Country:US
Mailing Address - Phone:626-339-4999
Mailing Address - Fax:
Practice Address - Street 1:45505 LEATHERWOOD AVE
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-1729
Practice Address - Country:US
Practice Address - Phone:661-488-8636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-27
Last Update Date:2025-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician