Healthcare Provider Details

I. General information

NPI: 1245195890
Provider Name (Legal Business Name): MELISSA PETERSON LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2025
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

784 CHAMBERS ST
OGDEN UT
84403-4567
US

IV. Provider business mailing address

784 CHAMBERS ST
OGDEN UT
84403-4567
US

V. Phone/Fax

Practice location:
  • Phone: 801-903-3671
  • Fax:
Mailing address:
  • Phone: 801-903-3671
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number340039-4701
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: