Provider Demographics
NPI:1871188557
Name:TYLER PETERSEN
Entity Type:Organization
Organization Name:TYLER PETERSEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:ROLLAND
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:801-919-4657
Mailing Address - Street 1:13351 S SHAUNNA LN
Mailing Address - Street 2:
Mailing Address - City:HERRIMAN
Mailing Address - State:UT
Mailing Address - Zip Code:84096-4706
Mailing Address - Country:US
Mailing Address - Phone:801-919-4657
Mailing Address - Fax:
Practice Address - Street 1:13351 S SHAUNNA LN
Practice Address - Street 2:
Practice Address - City:HERRIMAN
Practice Address - State:UT
Practice Address - Zip Code:84096-4706
Practice Address - Country:US
Practice Address - Phone:801-919-4657
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-04
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health