Healthcare Provider Details

I. General information

NPI: 1205778081
Provider Name (Legal Business Name): MCKENZIE PETERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2026
Last Update Date: 04/08/2026
Certification Date: 04/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 N MEDICAL DR
SALT LAKE CITY UT
84112-1100
US

IV. Provider business mailing address

9904 S ROSEBORO RD
SANDY UT
84092-3873
US

V. Phone/Fax

Practice location:
  • Phone: 801-587-3422
  • Fax:
Mailing address:
  • Phone: 801-232-1634
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number14271965-4201
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: