Provider Demographics
NPI:1619583721
Name:DE LA O-PETERSON, AMELIA FLORINDA (MA, LADC)
Entity type:Individual
Prefix:
First Name:AMELIA
Middle Name:FLORINDA
Last Name:DE LA O-PETERSON
Suffix:
Gender:F
Credentials:MA, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1246 UNIVERSITY AVE W
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-4125
Mailing Address - Country:US
Mailing Address - Phone:952-214-0266
Mailing Address - Fax:
Practice Address - Street 1:545 7TH ST W
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-3007
Practice Address - Country:US
Practice Address - Phone:612-767-0300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-23
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
MN3096101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)