Healthcare Provider Details

I. General information

NPI: 1447534268
Provider Name (Legal Business Name): NATHAN MARK PETERSON LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2011
Last Update Date: 11/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1459 N MAIN ST
BOUNTIFUL UT
84010-6092
US

IV. Provider business mailing address

1459 NORTH MAIN STREET
BOUNTIFUL UT
84010
US

V. Phone/Fax

Practice location:
  • Phone: 801-298-2000
  • Fax:
Mailing address:
  • Phone: 801-298-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number7350613-3501
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number7350613-3501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: