Provider Demographics
NPI:1356407290
Name:PETERSON, AMANDA ELIZABETH (LMHC)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:ELIZABETH
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 JOHNSWOOD RD
Mailing Address - Street 2:
Mailing Address - City:ROSLINDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02131-3748
Mailing Address - Country:US
Mailing Address - Phone:617-327-5554
Mailing Address - Fax:
Practice Address - Street 1:64 ELDREDGE ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02458-2017
Practice Address - Country:US
Practice Address - Phone:617-969-4925
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA309667101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health