Provider Demographics
NPI:1922408129
Name:PETERSON, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
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 1:2807 GREYSTONE COMM BLVD
Mailing Address - Street 2:SUITE 34
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35242-9601
Mailing Address - Country:US
Mailing Address - Phone:205-745-3660
Mailing Address - Fax:205-408-4209
Practice Address - Street 1:205 COUNTRY CLUB PARK
Practice Address - Street 2:
Practice Address - City:MOUNTAIN BRK
Practice Address - State:AL
Practice Address - Zip Code:35213-4237
Practice Address - Country:US
Practice Address - Phone:205-871-0777
Practice Address - Fax:205-871-0701
Is Sole Proprietor?:No
Enumeration Date:2014-08-26
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH7268225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist