Provider Demographics
NPI:1770960452
Name:PETERSEN, TYLER ROLLAND (CSW)
Entity type:Individual
Prefix:MR
First Name:TYLER
Middle Name:ROLLAND
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13351 S SHAUNNA LN
Mailing Address - Street 2:
Mailing Address - City:HERRIMAN
Mailing Address - State:UT
Mailing Address - Zip Code:84096-4706
Mailing Address - Country:US
Mailing Address - Phone:801-915-6055
Mailing Address - Fax:
Practice Address - Street 1:13351 S SHAUNNA LANE
Practice Address - Street 2:
Practice Address - City:HERRIMAN
Practice Address - State:UT
Practice Address - Zip Code:84096
Practice Address - Country:US
Practice Address - Phone:801-915-6055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-01
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5919098-35021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical