Provider Demographics
NPI:1801037205
Name:PETERSON, SCOTT ROBERT (LCSW)
Entity type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:ROBERT
Last Name:PETERSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 E 5600 S
Mailing Address - Street 2:SUITE 204
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-6181
Mailing Address - Country:US
Mailing Address - Phone:801-979-8182
Mailing Address - Fax:801-262-9991
Practice Address - Street 1:151 E 5600 S
Practice Address - Street 2:SUITE 204
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-6181
Practice Address - Country:US
Practice Address - Phone:801-979-8182
Practice Address - Fax:801-262-9991
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-13
Last Update Date:2009-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT141102-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical