Provider Demographics
NPI:1063717569
Name:PETERS, REBECCA (LCSW)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:PETERS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 W BROADWAY
Mailing Address - Street 2:SUITE 206
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84101-1722
Mailing Address - Country:US
Mailing Address - Phone:801-739-8611
Mailing Address - Fax:801-606-7197
Practice Address - Street 1:360 W BROADWAY
Practice Address - Street 2:SUITE 206
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84101-1722
Practice Address - Country:US
Practice Address - Phone:801-739-8611
Practice Address - Fax:801-606-7197
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-14
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4775428-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical