Provider Demographics
NPI:1447441464
Name:PETERSON, CORA MICHELLE (LPC)
Entity type:Individual
Prefix:MS
First Name:CORA
Middle Name:MICHELLE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 E 700 S # 1
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-4006
Mailing Address - Country:US
Mailing Address - Phone:801-860-1516
Mailing Address - Fax:801-575-8796
Practice Address - Street 1:3809 W 6200 S
Practice Address - Street 2:
Practice Address - City:KEARNS
Practice Address - State:UT
Practice Address - Zip Code:84118-3725
Practice Address - Country:US
Practice Address - Phone:801-560-1548
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-06
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT319272-6004101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional