Provider Demographics
NPI:1568916260
Name:PETERSEN, SANDRA
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:CECILIA
Other - Last Name:PERAZA -DOMINGUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:474 W 200 N STE 300
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-4505
Mailing Address - Country:US
Mailing Address - Phone:435-634-5600
Mailing Address - Fax:435-634-8700
Practice Address - Street 1:474 W 200 N
Practice Address - Street 2:
Practice Address - City:SAINT GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-4505
Practice Address - Country:US
Practice Address - Phone:435-634-5600
Practice Address - Fax:435-634-8700
Is Sole Proprietor?:No
Enumeration Date:2016-08-10
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10254931-3902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist