Provider Demographics
NPI:1932821220
Name:PETERSON, MACY
Entity type:Individual
Prefix:
First Name:MACY
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9080 N 5200 W
Mailing Address - Street 2:
Mailing Address - City:ELWOOD
Mailing Address - State:UT
Mailing Address - Zip Code:84337-8640
Mailing Address - Country:US
Mailing Address - Phone:435-200-5208
Mailing Address - Fax:
Practice Address - Street 1:338 W 300 N
Practice Address - Street 2:
Practice Address - City:HYDE PARK
Practice Address - State:UT
Practice Address - Zip Code:84318-4044
Practice Address - Country:US
Practice Address - Phone:435-200-5208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-14
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13023209-6009101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty