Provider Demographics
NPI:1902170996
Name:PETERSON, AMANDA LEE (PCC, LICDC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LEE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PCC, LICDC
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:LEE
Other - Last Name:FLEMING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PC, LCDCIII
Mailing Address - Street 1:975 KINGSVIEW DRIVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:LEBANON
Mailing Address - State:OH
Mailing Address - Zip Code:45036
Mailing Address - Country:US
Mailing Address - Phone:513-228-7800
Mailing Address - Fax:513-228-7848
Practice Address - Street 1:975 KINGSVIEW DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OH
Practice Address - Zip Code:45036-9562
Practice Address - Country:US
Practice Address - Phone:513-228-7800
Practice Address - Fax:513-228-7848
Is Sole Proprietor?:No
Enumeration Date:2012-03-08
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.0800170101YP2500X
OHICDC.100327101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)