Provider Demographics
NPI:1952861080
Name:PETTERSSON, JOSPEH NICHOLAS
Entity Type:Individual
Prefix:
First Name:JOSPEH
Middle Name:NICHOLAS
Last Name:PETTERSSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 N STATE ROAD 198
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:UT
Mailing Address - Zip Code:84653-5719
Mailing Address - Country:US
Mailing Address - Phone:801-423-3000
Mailing Address - Fax:
Practice Address - Street 1:345 N STATE ROAD 198
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:UT
Practice Address - Zip Code:84653-5719
Practice Address - Country:US
Practice Address - Phone:801-423-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-24
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician