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General NPI Number Information
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NPI Number | 1104764935
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Entity Type | Individual
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Provider Name | STACY NOELANI PETTERSSON CHMC AND MHC
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Gender | Female
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Dates
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Enumeration Date | 03/23/2026
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Last Update Date | 03/23/2026
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Provider Practice Location Address
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Address Line | 3696 W SAVANNAH CIR
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City | WEST JORDAN
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State | UT
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Zip | 84084-1710
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Country | US
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Telephone | 801-336-7624
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Fax |
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Provider Business Mailing Address
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Address Line | 85 DELANCEY ST
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City | NEW YORK
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State | NY
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Zip | 10002-3182
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Country | US
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Telephone | 646-941-7645
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Fax | 929-596-7897
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 929
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License Number State | HI
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 13811151-6004
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License Number State | UT
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