Provider Demographics
NPI:1043443617
Name:PETERSON, MARIAH (LCSW)
Entity type:Individual
Prefix:
First Name:MARIAH
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MARIAH
Other - Middle Name:
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:455 S 700 E UNIT 4213
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-3884
Mailing Address - Country:US
Mailing Address - Phone:303-909-0286
Mailing Address - Fax:
Practice Address - Street 1:2150 S 1300 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-4333
Practice Address - Country:US
Practice Address - Phone:303-909-0286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-31
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO14781041C0700X
UT10509741-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical