Provider Demographics
NPI:1154628311
Name:PETERSEN, BRADY PAUL
Entity Type:Individual
Prefix:MR
First Name:BRADY
Middle Name:PAUL
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:862 S MAIN ST
Mailing Address - Street 2:#4
Mailing Address - City:BRIGHAM CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84302-3320
Mailing Address - Country:US
Mailing Address - Phone:435-723-1795
Mailing Address - Fax:
Practice Address - Street 1:862 S MAIN ST
Practice Address - Street 2:#4
Practice Address - City:BRIGHAM CITY
Practice Address - State:UT
Practice Address - Zip Code:84302-3320
Practice Address - Country:US
Practice Address - Phone:435-723-1795
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-23
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency