Provider Demographics
NPI:1164574018
Name:PETERSON, DIANE J (LMFT)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:J
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:241 E 4200 N
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-5010
Mailing Address - Country:US
Mailing Address - Phone:801-226-3424
Mailing Address - Fax:
Practice Address - Street 1:3325 N UNIVERSITY AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-4465
Practice Address - Country:US
Practice Address - Phone:801-226-3008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT97-323498-3902101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health