Provider Demographics
NPI:1639977317
Name:PETERSEN, RAY ALBERT (ACMHC)
Entity type:Individual
Prefix:
First Name:RAY
Middle Name:ALBERT
Last Name:PETERSEN
Suffix:
Gender:
Credentials:ACMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1095 N TAFFETA DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84116-1740
Mailing Address - Country:US
Mailing Address - Phone:385-743-2444
Mailing Address - Fax:
Practice Address - Street 1:1095 N TAFFETA DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84116-1740
Practice Address - Country:US
Practice Address - Phone:385-743-2444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-06
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT14207610-6009101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health