Provider Demographics
NPI:1235013608
Name:PETERSEN, TANNER
Entity type:Individual
Prefix:
First Name:TANNER
Middle Name:
Last Name:PETERSEN
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 1:5868 KRISTINA PL
Mailing Address - Street 2:
Mailing Address - City:ROHNERT PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94928-5066
Mailing Address - Country:US
Mailing Address - Phone:707-569-4811
Mailing Address - Fax:
Practice Address - Street 1:5868 KRISTINA PL
Practice Address - Street 2:
Practice Address - City:ROHNERT PARK
Practice Address - State:CA
Practice Address - Zip Code:94928-5066
Practice Address - Country:US
Practice Address - Phone:707-569-4811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-31
Last Update Date:2025-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician