Provider Demographics
NPI:1700535747
Name:PETERSON, DANIEL RAYMOND (ACMHC)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:RAYMOND
Last Name:PETERSON
Suffix:
Gender:M
Credentials:ACMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4655 S LOCUST LN APT 3
Mailing Address - Street 2:
Mailing Address - City:HOLLADAY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-5245
Mailing Address - Country:US
Mailing Address - Phone:801-313-7900
Mailing Address - Fax:
Practice Address - Street 1:5770 S 1500 W
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84123-5216
Practice Address - Country:US
Practice Address - Phone:801-313-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-18
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12632742-6009101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional