Provider Demographics
NPI:1225484850
Name:PETERSON, AMANTHA H
Entity Type:Individual
Prefix:
First Name:AMANTHA
Middle Name:H
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8136 OLD KEENE MILL RD
Mailing Address - Street 2:A-302
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22152-1850
Mailing Address - Country:US
Mailing Address - Phone:703-913-8563
Mailing Address - Fax:703-913-8565
Practice Address - Street 1:8136 OLD KEENE MILL RD
Practice Address - Street 2:A-302
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22152-1850
Practice Address - Country:US
Practice Address - Phone:703-913-8563
Practice Address - Fax:703-913-8565
Is Sole Proprietor?:No
Enumeration Date:2016-05-12
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040081461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical