Doctor Name: | DR. CALVIN ROSS PETERSEN |
NPI Number: | 1215964028 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | |
License Number: | 108181-2501 |
Business Practice Address: | 1755 N 400 E North Logan, UT - 843411954 |
Business Phone Number: | 4357530272 |
Business Fax Number: | 4357532252 |
Mailing Address: | 1755 N 400 E, NORTH LOGAN |
State: | UT |
Postal Code: | 843411960 |
Phone Number: | 4357530272 |
Fax Number: | 4357532252 |
NPI Enumeration Date: | 06/27/2006 |
NPI Last Update Date: | 07/09/2007 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 103TC0700X |
License Number: | 108181-2501 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | UT |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Psychologist |
Taxonomy Specialization: | Clinical |
Taxonomy Definition: |