Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 104100000X | Social Worker |
NPI | 1003418179 |
---|---|
Provider Name | Kimberly Petersen |
First Address | Salt Lake City, UT 84121-1359 |
Second Address | Salt Lake City, UT 84121-1359 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/11/2020 |
Last Update Date | 12/11/2020 |