Provider Demographics
NPI:1043090822
Name:PETA, WAKIYAN (LAC)
Entity type:Individual
Prefix:
First Name:WAKIYAN
Middle Name:
Last Name:PETA
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 83
Mailing Address - Street 2:
Mailing Address - City:LANTRY
Mailing Address - State:SD
Mailing Address - Zip Code:57636-0083
Mailing Address - Country:US
Mailing Address - Phone:605-200-5052
Mailing Address - Fax:
Practice Address - Street 1:24276 166TH ST
Practice Address - Street 2:
Practice Address - City:EAGLE BUTTE
Practice Address - State:SD
Practice Address - Zip Code:57625-8141
Practice Address - Country:US
Practice Address - Phone:605-964-0722
Practice Address - Fax:605-964-8905
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-29
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD7051316101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty