Provider Demographics
NPI:1588179634
Name:PETERSON, AMANDA L
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:L
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 1:220 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54901-5030
Mailing Address - Country:US
Mailing Address - Phone:920-236-4700
Mailing Address - Fax:920-236-1157
Practice Address - Street 1:211 N COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-2678
Practice Address - Country:US
Practice Address - Phone:920-729-2777
Practice Address - Fax:920-720-9682
Is Sole Proprietor?:No
Enumeration Date:2017-12-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical