Provider Demographics
NPI:1013229673
Name:PETERS, AMY MARIE (MED, CCC-SLP, BCBA)
Entity Type:Individual
Prefix:MS
First Name:AMY
Middle Name:MARIE
Last Name:PETERS
Suffix:
Gender:F
Credentials:MED, CCC-SLP, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3986 LILAC LN
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN GREEN
Mailing Address - State:UT
Mailing Address - Zip Code:84050-6800
Mailing Address - Country:US
Mailing Address - Phone:801-876-3949
Mailing Address - Fax:
Practice Address - Street 1:3986 LILAC LN
Practice Address - Street 2:
Practice Address - City:MOUNTAIN GREEN
Practice Address - State:UT
Practice Address - Zip Code:84050-6800
Practice Address - Country:US
Practice Address - Phone:801-876-3949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-11
Last Update Date:2010-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1-10-7242103K00000X
UT09138092235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist