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General NPI Number Information
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NPI Number | 1679764989
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Entity Type | Individual
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Provider Name | DAVID H PETERSEN LCSW
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Gender | Male
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Dates
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Enumeration Date | 08/05/2007
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Last Update Date | 11/02/2016
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Provider Practice Location Address
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Address Line | 6112 S 1550 E
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City | OGDEN
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State | UT
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Zip | 84405-5007
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Country | US
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Telephone | 801-589-5251
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Fax |
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Provider Business Mailing Address
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Address Line | 6112 S. 1550 E. SKYLINE DR.
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City | OGDEN
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State | UT
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Zip | 84405-5007
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Country | US
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Telephone | 801-589-5251
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Fax |
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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 | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 108132-3501
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License Number State | UT
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