Provider Demographics
NPI:1194277749
Name:PETERSON, ELISE ROSE LICHTENBERG (MSOTR/L)
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:ROSE LICHTENBERG
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MSOTR/L
Other - Prefix:
Other - First Name:ELISE
Other - Middle Name:ROSE
Other - Last Name:LICHTENBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSOTR/L
Mailing Address - Street 1:100 N MARIO CAPECCHI DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84113-1103
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 N MARIO CAPECCHI DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84113-1103
Practice Address - Country:US
Practice Address - Phone:801-662-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-31
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10143483-4201225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT942854057Medicaid