Provider Demographics
NPI:1124160262
Name:PETERSON, WAYNE DOUGLAS (LPC)
Entity type:Individual
Prefix:MR
First Name:WAYNE
Middle Name:DOUGLAS
Last Name:PETERSON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:MR
Other - First Name:DOUGLAS
Other - Middle Name:
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:PO BOX 662
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84701-0662
Mailing Address - Country:US
Mailing Address - Phone:435-201-4481
Mailing Address - Fax:
Practice Address - Street 1:164 N MAIN ST
Practice Address - Street 2:(REAR)
Practice Address - City:RICHFIELD
Practice Address - State:UT
Practice Address - Zip Code:84701-2170
Practice Address - Country:US
Practice Address - Phone:435-201-4481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3690346004101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
36903460000001OtherREGENCE BLUE CROSS BLUE S
86695OtherPEHP