Provider Demographics
NPI:1942813126
Name:PETERSON, KELSEY LIN
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:LIN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2186 E HAWTHORNE ST
Mailing Address - Street 2:
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:UT
Mailing Address - Zip Code:84043-2408
Mailing Address - Country:US
Mailing Address - Phone:801-899-7327
Mailing Address - Fax:
Practice Address - Street 1:5698 W GLEN EAGLE DR
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84128-4013
Practice Address - Country:US
Practice Address - Phone:801-917-5457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-26
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical