Basic Information
| Provider Information | |||||||||
| NPI: | 1700102837 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | AMELIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4747 N 7TH ST | ||||||||
| Address2: | STE. 100 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850143653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022797655 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1930 S ALMA SCHOOL RD | ||||||||
| Address2: | A104 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852103064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808200825 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2010 | ||||||||
| LastUpdateDate: | 04/14/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.