Provider Demographics
NPI:1730828039
Name:PETERSON, SAMANTHA LUANN (CM)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LUANN
Last Name:PETERSON
Suffix:
Gender:M
Credentials:CM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 N NAYON DR
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84040-2875
Mailing Address - Country:US
Mailing Address - Phone:801-882-0286
Mailing Address - Fax:
Practice Address - Street 1:1808 W 1800 N STE A
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:UT
Practice Address - Zip Code:84015-8503
Practice Address - Country:US
Practice Address - Phone:801-217-3133
Practice Address - Fax:801-528-5067
Is Sole Proprietor?:No
Enumeration Date:2022-06-03
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
UT13952862-4701225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator