Provider Demographics
NPI:1235434176
Name:PETERSDORF, AMY K (MA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:K
Last Name:PETERSDORF
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10702 W BURLEIGH ST
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53222-3310
Mailing Address - Country:US
Mailing Address - Phone:414-777-0740
Mailing Address - Fax:414-777-0749
Practice Address - Street 1:10702 W BURLEIGH ST
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53222-3310
Practice Address - Country:US
Practice Address - Phone:414-777-0740
Practice Address - Fax:414-777-0749
Is Sole Proprietor?:No
Enumeration Date:2011-01-25
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4667-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional