MEDICARE: MR. DAVID H 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	108132-3501	UT

General Provider Information

NPI Number	:	1679764989
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DAVID H PETERSEN LCSW

Provider Business Mailing Address
First Line	:	6112 S. 1550 E. SKYLINE DR.
Second Line	:
City	:	OGDEN
State	:	UT
Zip	:	84405-5007
Country	:	US
Telephone Number	:	801-589-5251
Fax Number	:

Provider Business Practice Location Address
First Line	:	6112 S 1550 E
Second Line	:
City	:	OGDEN
State	:	UT
Zip	:	84405-5007
Country	:	US
Telephone Number	:	801-589-5251
Fax Number	:

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

Provider Enumeration Date	:	08/05/2007
Last Update Date	:	11/02/2016

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