MEDICARE: BRIAN LAMAR PETERSEN 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	117747-3501	UT

General Provider Information

NPI Number	:	1659544773
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIAN LAMAR PETERSEN LCSW

Provider Business Mailing Address
First Line	:	3724 S 2000 E
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84109-3318
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3724 S 2000 E
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84109-3318
Country	:	US
Telephone Number	:	801-272-5138
Fax Number	:

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

Provider Enumeration Date	:	04/09/2008
Last Update Date	:	04/09/2008

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