Provider Demographics
NPI:1679541189
Name:PETERS, BONNIE L (LCSW)
Entity Type:Individual
Prefix:MS
First Name:BONNIE
Middle Name:L
Last Name:PETERS
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 1:777 W CENTER ST
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-7148
Mailing Address - Country:US
Mailing Address - Phone:801-255-6881
Mailing Address - Fax:801-562-9347
Practice Address - Street 1:777 W CENTER ST
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-7148
Practice Address - Country:US
Practice Address - Phone:801-255-6881
Practice Address - Fax:801-562-9347
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT14120435011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical