Individual
MR. WAYNE DOUGLAS PETERSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
LPC
Contact information
Practice address
164 N MAIN ST, (REAR), RICHFIELD, UT 84701-2170
(435) 201-4481
Mailing address
PO BOX 662, RICHFIELD, UT 84701-0662
(435) 201-4481
Taxonomy
Speciality
Code
Description
License number
State
101YP2500X
Professional Counselor
Primary
3690346004
UT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
36903460000001
REGENCE BLUE CROSS BLUE S
—
01
—
86695
PEHP
—
Enumeration date
02/13/2007
Last updated
07/08/2007
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