MEDICARE: MRS. AMY KATHRYN PETERSEN OTR L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	0119000197	VA

General Provider Information

NPI Number	:	1689731796
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. AMY KATHRYN PETERSEN OTR L

Provider Business Mailing Address
First Line	:	5209 BALBOA DR
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23464-2610
Country	:	US
Telephone Number	:	757-406-6199
Fax Number	:

Provider Business Practice Location Address
First Line	:	5209 BALBOA DR
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23464-2610
Country	:	US
Telephone Number	:	757-406-6199
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/02/2007
Last Update Date	:	09/07/2010

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