Provider Demographics
NPI:1285382739
Name:PETERSEN, TAYLOR GARRETT
Entity type:Individual
Prefix:MR
First Name:TAYLOR
Middle Name:GARRETT
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4059 S 895 E
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-2415
Mailing Address - Country:US
Mailing Address - Phone:801-529-2121
Mailing Address - Fax:
Practice Address - Street 1:5300 S 500 E STE 6
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-6955
Practice Address - Country:US
Practice Address - Phone:801-392-0942
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-14
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical