Provider Demographics
NPI:1609856053
Name:PETERSON, PENNY L (LCSW)
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:L
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 LAKE PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84120-8230
Mailing Address - Country:US
Mailing Address - Phone:801-982-3085
Mailing Address - Fax:855-525-7075
Practice Address - Street 1:2525 LAKE PARK BLVD
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84120-8230
Practice Address - Country:US
Practice Address - Phone:801-982-3085
Practice Address - Fax:855-525-7075
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2011-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13284235011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT13284235000001OtherBLUE CROSS
UT13284235000001OtherBLUE CROSS