Provider Demographics
NPI:1689731796
Name:PETERSEN, AMY KATHRYN (OTR L)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:KATHRYN
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:OTR L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5209 BALBOA DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-2610
Mailing Address - Country:US
Mailing Address - Phone:757-406-6199
Mailing Address - Fax:
Practice Address - Street 1:5209 BALBOA DR
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-2610
Practice Address - Country:US
Practice Address - Phone:757-406-6199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119000197225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist