Provider Demographics
NPI:1295607513
Name:PETERSON, TAYA RAE
Entity type:Individual
Prefix:
First Name:TAYA
Middle Name:RAE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 264
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84028-0264
Mailing Address - Country:US
Mailing Address - Phone:435-757-6207
Mailing Address - Fax:
Practice Address - Street 1:1235 LAKEVIEW DR
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:UT
Practice Address - Zip Code:84028-0264
Practice Address - Country:US
Practice Address - Phone:435-757-6207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-18
Last Update Date:2025-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT14202810-6009101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health