Provider Demographics
NPI:1679110779
Name:PETERSON, AMY (LPC-IT)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6905 BOBOLINK RD
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53402-1344
Mailing Address - Country:US
Mailing Address - Phone:262-221-7200
Mailing Address - Fax:
Practice Address - Street 1:6233 DURAND AVE STE F
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53406-4961
Practice Address - Country:US
Practice Address - Phone:262-554-8165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-08
Last Update Date:2019-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4510226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional