Healthcare Provider Details

I. General information

NPI: 1750067823
Provider Name (Legal Business Name): AMY KATHLEEN PETERSEN LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2023
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 S STATE ST
ZEELAND MI
49464-2060
US

IV. Provider business mailing address

300 68TH ST SE
GRAND RAPIDS MI
49548-6927
US

V. Phone/Fax

Practice location:
  • Phone: 616-741-3790
  • Fax: 616-741-3792
Mailing address:
  • Phone: 616-455-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401225669
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: