Provider Demographics
NPI:1093107633
Name:PETERSON, EDWARD CHASE (LCSW, MBA)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:CHASE
Last Name:PETERSON
Suffix:
Gender:M
Credentials:LCSW, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 W PRINCETON DR
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-7513
Mailing Address - Country:US
Mailing Address - Phone:801-809-7990
Mailing Address - Fax:
Practice Address - Street 1:27 W PRINCETON DR
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-7513
Practice Address - Country:US
Practice Address - Phone:801-809-7990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-18
Last Update Date:2015-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8454347-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical