MEDICARE: MR. CLIFTON KENT PETERSON L.C.S.W.

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	123917-3501	UT

General Provider Information

NPI Number	:	1679815864
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CLIFTON KENT PETERSON L.C.S.W.

Provider Business Mailing Address
First Line	:	9192 S 300 W
Second Line	:	SUITE 19
City	:	SANDY
State	:	UT
Zip	:	84070-2671
Country	:	US
Telephone Number	:	801-949-1199
Fax Number	:

Provider Business Practice Location Address
First Line	:	9192 S 300 W
Second Line	:	SUITE 19
City	:	SANDY
State	:	UT
Zip	:	84070-2671
Country	:	US
Telephone Number	:	801-949-1199
Fax Number	:

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

Provider Enumeration Date	:	03/26/2013
Last Update Date	:	03/26/2013

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