Provider Demographics
NPI:1447534268
Name:PETERSON, NATHAN MARK (LCSW)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:MARK
Last Name:PETERSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1459 NORTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010
Mailing Address - Country:US
Mailing Address - Phone:801-298-2000
Mailing Address - Fax:
Practice Address - Street 1:1459 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-6092
Practice Address - Country:US
Practice Address - Phone:801-298-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-29
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7350613-35011041C0700X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT876000308007Medicaid
UT260022408OtherRAILROAD MEDICARE
UT260022408OtherRAILROAD MEDICARE