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NPI Code Detail

MEDICARE: BREANNA PETERSON

MEDICARE: BREANNA PETERSON
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1106S00000XBehavior Technician

General Provider Information

NPI Number : 1225634538
Entity Type Code : Individual
Provider Name (Legal Business Name) : BREANNA PETERSON
Provider Business Mailing Address
First Line : 12223 S 1740 W
Second Line :
City : RIVERTON
State : UT
Zip : 84065-3148
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 2540 E BENGAL BLVD STE 300
Second Line :
City : COTTONWOOD HEIGHTS
State : UT
Zip : 84121-5157
Country : US
Telephone Number : 801-495-5100
Fax Number : 801-495-5102
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/10/2020
Last Update Date : 12/10/2020

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Directions to “ BREANNA PETERSON ” Practice Location

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