Provider Demographics
NPI:1679815864
Name:PETERSON, CLIFTON KENT (LCSW)
Entity Type:Individual
Prefix:MR
First Name:CLIFTON
Middle Name:KENT
Last Name:PETERSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9192 S 300 W
Mailing Address - Street 2:SUITE 19
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-2671
Mailing Address - Country:US
Mailing Address - Phone:801-949-1199
Mailing Address - Fax:
Practice Address - Street 1:9192 S 300 W
Practice Address - Street 2:SUITE 19
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-2671
Practice Address - Country:US
Practice Address - Phone:801-949-1199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-26
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT123917-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical