Provider Demographics
NPI:1104436708
Name:PETERS, AMANDA JEAN (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:JEAN
Last Name:PETERS
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7201 RANCH ROAD 2222 APT 1318
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78730-3214
Mailing Address - Country:US
Mailing Address - Phone:224-703-1824
Mailing Address - Fax:
Practice Address - Street 1:128 E OLIN AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53713-1467
Practice Address - Country:US
Practice Address - Phone:608-252-1320
Practice Address - Fax:608-252-1333
Is Sole Proprietor?:No
Enumeration Date:2020-08-07
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX116037235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI6093OtherWI DEPARTMENT OF SAFETY AND PROFESSIONAL SERVICES