Provider Demographics
NPI:1043780125
Name:PETERSEN, AMY DEVANNEY (LCSW)
Entity type:Individual
Prefix:MS
First Name:AMY
Middle Name:DEVANNEY
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3251 LOWELL BLVD APT 416
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80211-3282
Mailing Address - Country:US
Mailing Address - Phone:917-943-0849
Mailing Address - Fax:
Practice Address - Street 1:3251 LOWELL BLVD APT 416
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80211-3282
Practice Address - Country:US
Practice Address - Phone:917-943-0849
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-30
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY095411104100000X
NY0883681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty