Provider Demographics
NPI:1568917664
Name:PETERSON, AMANDA (OT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3676 W EVENING SKY LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84009-3105
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5171 S COTTONWOOD ST
Practice Address - Street 2:LOWER LEVEL 2 WOMEN'S CENTER COORDINATED REHAB SERVICES
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-5704
Practice Address - Country:US
Practice Address - Phone:801-507-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-18
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3460604201225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation