Healthcare Provider Details

I. General information

NPI: 1801037205
Provider Name (Legal Business Name): SCOTT ROBERT PETERSON LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2009
Last Update Date: 03/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 E 5600 S SUITE 204
MURRAY UT
84107-6181
US

IV. Provider business mailing address

151 E 5600 S SUITE 204
MURRAY UT
84107-6181
US

V. Phone/Fax

Practice location:
  • Phone: 801-979-8182
  • Fax: 801-262-9991
Mailing address:
  • Phone: 801-979-8182
  • Fax: 801-262-9991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number141102-3501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: