Doctor Name: | MR. WAYNE DOUGLAS PETERSON |
NPI Number: | 1124160262 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | LPC |
License Number: | 3690346004 |
Business Practice Address: | 164 N Main St (rear) Richfield, UT - 847012170 |
Business Phone Number: | 4352014481 |
Business Fax Number: | |
Mailing Address: | Po Box 662, RICHFIELD |
State: | UT |
Postal Code: | 847010662 |
Phone Number: | 4352014481 |
Fax Number: | |
NPI Enumeration Date: | 02/13/2007 |
NPI Last Update Date: | 07/08/2007 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 101YP2500X |
License Number: | 3690346004 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | UT |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Counselor |
Taxonomy Specialization: | Professional |
Taxonomy Definition: |