Provider Demographics
NPI:1376945360
Name:PETERSON, EATHYN
Entity Type:Individual
Prefix:
First Name:EATHYN
Middle Name:
Last Name:PETERSON
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 1:335 S. RAILROAD AVE
Mailing Address - Street 2:
Mailing Address - City:DILLON
Mailing Address - State:MT
Mailing Address - Zip Code:59725
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1435 VILLAGE DRIVE
Practice Address - Street 2:DEPT. 2801
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84408
Practice Address - Country:US
Practice Address - Phone:801-626-7389
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-22
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer