MEDICARE: TAYA RAE PETERSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	14202810-6009	UT

General Provider Information

NPI Number	:	1295607513
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAYA RAE PETERSON

Provider Business Mailing Address
First Line	:	PO BOX 264
Second Line	:
City	:	GARDEN CITY
State	:	UT
Zip	:	84028-0264
Country	:	US
Telephone Number	:	435-757-6207
Fax Number	:

Provider Business Practice Location Address
First Line	:	1235 LAKEVIEW DR
Second Line	:
City	:	GARDEN CITY
State	:	UT
Zip	:	84028-0264
Country	:	US
Telephone Number	:	435-757-6207
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/18/2025
Last Update Date	:	09/18/2025

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Directions to “ TAYA RAE PETERSON ” Practice Location

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