MEDICARE: AMY S PETERSON LADC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	306417	MN

General Provider Information

NPI Number	:	1598617227
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY S PETERSON LADC

Provider Business Mailing Address
First Line	:	8444 N 90TH ST STE 100
Second Line	:
City	:	SCOTTSDALE
State	:	AZ
Zip	:	85258-4437
Country	:	US
Telephone Number	:	602-248-8886
Fax Number	:

Provider Business Practice Location Address
First Line	:	1020 W BROADWAY AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55411-2504
Country	:	US
Telephone Number	:	612-895-3850
Fax Number	:

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

Provider Enumeration Date	:	02/13/2026
Last Update Date	:	02/13/2026

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