Healthcare Provider Details

I. General information

NPI: 1679454284
Provider Name (Legal Business Name): AMANDA LYNN PETERSEN CDCA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA L PETERSEN PEER SUPPORT

II. Dates (important events)

Enumeration Date: 09/10/2025
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

624 MARKET AVE N
CANTON OH
44702-1017
US

IV. Provider business mailing address

624 MARKET AVE N
CANTON OH
44702-1017
US

V. Phone/Fax

Practice location:
  • Phone: 330-479-1912
  • Fax: 330-497-0677
Mailing address:
  • Phone: 330-479-1912
  • Fax: 330-497-0677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberOCPS.161571
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.193508
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: