Provider Demographics
NPI:1467989293
Name:PETERSON, MEGAN A (LMT)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:A
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1153 E 3900 S
Mailing Address - Street 2:
Mailing Address - City:MILLCREEK
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1201
Mailing Address - Country:US
Mailing Address - Phone:801-262-6331
Mailing Address - Fax:801-262-3372
Practice Address - Street 1:1153 E 3900 S
Practice Address - Street 2:
Practice Address - City:MILLCREEK
Practice Address - State:UT
Practice Address - Zip Code:84124-1201
Practice Address - Country:US
Practice Address - Phone:801-262-6331
Practice Address - Fax:801-262-3372
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9653187-5701225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist