Provider Demographics
NPI:1255797890
Name:PETERSON, SUSAN (CMHC)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:CMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4501 N UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-5504
Mailing Address - Country:US
Mailing Address - Phone:801-227-2057
Mailing Address - Fax:801-227-2095
Practice Address - Street 1:4501 N UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-5504
Practice Address - Country:US
Practice Address - Phone:801-227-2057
Practice Address - Fax:801-227-2095
Is Sole Proprietor?:No
Enumeration Date:2016-01-12
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5476575-6004101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health