Healthcare Provider Details

I. General information

NPI: 1104764935
Provider Name (Legal Business Name): STACY NOELANI PETTERSSON CHMC AND MHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2026
Last Update Date: 03/23/2026
Certification Date: 03/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3696 W SAVANNAH CIR
WEST JORDAN UT
84084-1710
US

IV. Provider business mailing address

85 DELANCEY ST
NEW YORK NY
10002-3182
US

V. Phone/Fax

Practice location:
  • Phone: 801-336-7624
  • Fax:
Mailing address:
  • Phone: 646-941-7645
  • Fax: 929-596-7897

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number929
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number13811151-6004
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: