Provider Demographics
NPI:1306019484
Name:PETERSEN, AMY (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 ATKINS DR
Mailing Address - Street 2:
Mailing Address - City:TEA
Mailing Address - State:SD
Mailing Address - Zip Code:57064-2082
Mailing Address - Country:US
Mailing Address - Phone:605-366-0103
Mailing Address - Fax:
Practice Address - Street 1:130 ATKINS DR
Practice Address - Street 2:
Practice Address - City:TEA
Practice Address - State:SD
Practice Address - Zip Code:57064-2082
Practice Address - Country:US
Practice Address - Phone:605-366-0103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-09
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist