MEDICARE: MS. LACEY JEAN PETERSON LCSW

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
1	1041C0700X	Clinical Social Worker	11115847-3501	UT
2	1041C0700X	Clinical Social Worker	CSW.09926230	CO

General Provider Information

NPI Number	:	1598285025
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LACEY JEAN PETERSON LCSW

Provider Business Mailing Address
First Line	:	2398 E PRAIRIE LN
Second Line	:
City	:	EAGLE MOUNTAIN
State	:	UT
Zip	:	84005-3300
Country	:	US
Telephone Number	:	801-448-7898
Fax Number	:

Provider Business Practice Location Address
First Line	:	2398 E PRAIRIE LN
Second Line	:
City	:	EAGLE MOUNTAIN
State	:	UT
Zip	:	84005-3300
Country	:	US
Telephone Number	:	801-448-7898
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/26/2017
Last Update Date	:	02/08/2021

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