Healthcare Provider Details

I. General information

NPI: 1932821220
Provider Name (Legal Business Name): MACY PETERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2022
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 E CENTER ST STE 103
LOGAN UT
84321-5188
US

IV. Provider business mailing address

9080 N 5200 W
ELWOOD UT
84337-8640
US

V. Phone/Fax

Practice location:
  • Phone: 801-300-6610
  • Fax:
Mailing address:
  • Phone: 435-200-5208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number13023209-6009
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: