MEDICARE: PENNY L PETERSON LCSW

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	1041C0700X	Clinical Social Worker	1328423501	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	13284235000001	OTHER	UT	BLUE CROSS

General Provider Information

NPI Number	:	1609856053
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PENNY L PETERSON LCSW

Provider Business Mailing Address
First Line	:	2525 LAKE PARK BLVD
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84120-8230
Country	:	US
Telephone Number	:	801-982-3085
Fax Number	:	855-525-7075

Provider Business Practice Location Address
First Line	:	2525 LAKE PARK BLVD
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84120-8230
Country	:	US
Telephone Number	:	801-982-3085
Fax Number	:	855-525-7075

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

Provider Enumeration Date	:	01/20/2006
Last Update Date	:	07/25/2011

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