Provider Demographics
NPI:1043780125
Name:PETERSEN, AMY DEVANNEY (LMSW)
Entity Type:Individual
Prefix:MS
First Name:AMY
Middle Name:DEVANNEY
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3132 34TH ST APT 3R
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11106-1737
Mailing Address - Country:US
Mailing Address - Phone:248-404-7516
Mailing Address - Fax:
Practice Address - Street 1:478 10TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-4302
Practice Address - Country:US
Practice Address - Phone:248-404-7516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-30
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY095411104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty